ASSESSMENT OF QUALITY IMPROVEMENT STRATEGIES IN HEALTH CARE

Release Date:  January 22, 1999

RFA:  HS-99-002

P.T.

Agency for Health Care Policy and Research

Letter of Intent Receipt Date:  March 1, 1999
Application Receipt Date:  April 22, 1999

PURPOSE

The Agency for Health Care Policy and Research (AHCPR) announces the availability
of research grants to evaluate strategies for improving health care quality.  The
projects undertaken as a result of this Request for Applications (RFA) will
analyze the relative utility and costs of various approaches to health care
quality improvement.  The fundamental long-term goal of this effort is to
strengthen the evidence base underlying the choice of strategies to employ when
attempting to improve the quality of clinical care.  Studies should focus on
comparing improvement efforts which target those areas where the greatest
improvements in health and functional status can occur, reliable and valid
quality measures exist, and a variety of strategies are being employed. 
Partnerships between academic and other research organizations with existing
health care quality improvement efforts through established mechanisms such as
Peer Review Organizations (PROs), Quality Improvement Organizations (QIOs),
purchaser groups, health plans, and accrediting bodies are required under this
RFA.

This Request for Applications (RFA) is one in a series of RFAs to support
research on quality of health care issued by AHCPR over the last several weeks.
These initiatives respond to the report, "Quality First, The President's
Commission on Consumer Protection and Quality in the Health Care Industry
(Commission)," which called for a significant investment in the further
development of research, tools, and information for patients, practitioners,
purchasers, and payers.

The three RFAs are:

1) Quality Measurement for Vulnerable Populations (HS-99-001) þ to develop and
test new quality measures that can be used in the purchase or improvement of
health care services for populations identified as vulnerable in the Commission
report; 2) Translating Research Into Practice (HS-99-003) þ to generate new
knowledge about approaches, both innovative and established, which are effective
and cost effective in promoting the use of rigorously derived evidence in
clinical settings and lead to improved health care practice and sustained
practitioner behavior change (with particular interest in studies that implement
AHCPR-supported evidence-based tools and information); and 3) Assessment of
Quality Improvement Strategies in Health Care (HS-99-002) þ to rigorously
evaluate strategies for improving health care quality which are currently in
widespread use by organized quality improvement systems (projects that would
expand the conceptual and methodological basis for improving clinical quality and
analyze the relative utility and costs of various approaches to quality
improvement).

In addition to their common context and theme, these three initiatives are also
designed to help build capacity in the field of health services research. This
is accomplished through the inclusion of specific incentives to attract
applications from qualified minority and junior faculty health services
researchers.

Special preference will be accorded to applications from investigators not
recently or currently funded as principal investigator of an AHCPR grant for
research on quality improvement strategies.  AHCPR also encourages minority
institutions to apply for funding under this solicitation, and encourages
collaboration on projects between minority institutions and majority
institutions. Minority institutions have had a significant role in delivering
health care to under-served communities and represent a valuable resource to
facilitate collaboration with those communities, while majority institutions
often bring greater research experience on quality of care improvement
strategies.

AHCPR is committed to achieving the goals of the President's Race and Health
Disparities Initiative:  Eliminating by the year 2010 the differences in outcomes
and health status for racial and ethnic minority populations in six clinical
areas (infant mortality, cancer screening and management, cardiovascular disease,
diabetes, HIV infection, and child and adult  immunization).  Many of these
disparities are not due to gaps in knowledge regarding disease processes, but are
largely the result of provider factors, patient factors, and organizational
factors which impair the implementation of existing knowledge. AHCPR seeks to
fund research projects which will strengthen the science base for implementing
and evaluating quality improvement strategies in minority populations in order
to achieve this ambitious goal.  For further information on this Initiative, see: 
http://raceandhealth.hhs.gov.

HEALTHY PEOPLE 2000

The Public Health Service (PHS) is committed to achieving the health promotion
and disease prevention objectives of "Healthy People 2000," a PHS-led national
activity for setting priority areas.  AHCPR encourages applicants to submit grant
applications with relevance to the specific objectives of this initiative. 
Potential applicants may obtain a copy of "Healthy People 2000" (Full Report:
Stock No. 017-001-00474-0 or Summary Report: Stock No. 017-001-00473-1) through
the Superintendent of Documents, Government Printing Office, Washington, DC
20402-9325, telephone 202-512-1800.

ELIGIBILITY REQUIREMENTS

Applications may be submitted by public or private nonprofit organizations,
including universities, clinics, units of State and local governments, nonprofit
firms, and nonprofit foundations. For-profit entities may participate as members
of consortia or subcontractors if the applicant is nonprofit. Organizations
described in section 501(c)4 of the Internal Revenue Code that engage in lobbying
are not eligible.

AHCPR encourages investigators who are women, members of minority groups, and
persons with disabilities to apply as Principal Investigators.

MECHANISM OF SUPPORT

This RFA will use the research project grant (R01) mechanism. The responsibility
for the planning, direction, and execution of the proposed project will be solely
that of the applicant.

The total project period for each application submitted in response to this RFA
may not exceed 3 years.  The earliest anticipated award date is September 1,
1999. At this time, AHCPR has not determined whether or how this solicitation
will be continued beyond this present RFA.

FUNDS AVAILABLE

AHCPR expects to award up to $2.0 million in fiscal year 1999 to support the
first year of approximately three to five projects under this RFA.  AHCPR will
set-aside approximately $500,000 of the $2.0 million to support projects which
address quality improvement strategies for racial and ethnic minority population
groups regarding the six clinical areas identified in the President's Race and
Health Disparities Initiative.

The number of awards is dependent on the number of high quality applications and
their individual budget requirements; it is not the intent of AHCPR that the
awards be equal in size. Funding beyond the initial budget period will depend
upon annual progress reviews by AHCPR and the availability of funds.

RESEARCH OBJECTIVES

Background

Recent years have seen a dramatic improvement in our ability to define and
measure health care quality through the application of clinical performance
measures, population-based surveys, and analyses of clinical data sets.  This
work has documented "serious and extensive" problems in health care quality
across a range of delivery systems, geographic areas, and practice settings
(Chassin, 1998).

Although advances in the measurement of quality are a necessary component of
health care quality improvement, they alone are not sufficient. Progress in
quality measurement has not been complemented by comparable advancement in our
ability to systematically translate that information into improvement. As a
result, a substantial gap between quality information and improvement has
developed which is likely to grow without focused research to provide an evidence
base for the application of quality improvement strategies in clinical policy
making.  This was recognized by the President's Advisory Commission on Consumer
Protection and Quality in the Health Care Industry, which recommended the
continued development and dissemination of evidence-based information to guide
management policies that can improve health care quality (President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry, 1998).

Over the last 3 decades a variety of approaches have been used to foster quality
improvement in health care. The adoption of industrial models for quality
improvement has been one method for addressing variations in health care quality
(Laffel, 1989).  Additional methods employed to improve health care quality have
included the use of regulations, focused incentives, behavioral interventions,
academic detailing, and the use of information systems. There have been some
documented success stories in applying these techniques to quality improvement
(Evans, 1997). Recent state and regional efforts have also attested to the
potential of quality improvement efforts for specific conditions such as ischemic
heart disease (Soumerai, 1998; Marciniak, 1998).

Despite these successes, health care quality improvement efforts have often been
met with skepticism from both providers and policy makers (Chassin, 1996).
Although the Health Care Financing Administration - through its Peer Review
Organizations - and the Joint Commission on the Accreditation of Healthcare
Organizations have embraced continuous quality improvement techniques in their
evaluations of providers, the effectiveness of this approach is still unclear. 
The few published evaluations of the value of quality improvement efforts which
have been conducted to date have shown mixed results.  For example, the
application of continuous quality improvement to the management of clinical
outcomes has shown some promise in non-randomized studies, but randomized trials
have failed to show a meaningful impact on clinical outcomes or organization wide
improvement (Shortell, 1998).  Recent work has identified the significant
barriers to the successful application of continuous quality improvement in
health care which may provide a first step to overcoming them (Blumenthal, 1998). 
Successful quality improvement programs have usually been conducted in single
institutions, addressed one condition with one intervention, had modest sample
sizes, and used historical controls.  Consequently, the interpretation of these
results and their generalizability have limited their utility in achieving more
global improvements in health care (Chassin, 1997).

This situation is unlikely to change without a fundamental understanding of which
quality improvement efforts work for particular conditions, populations and
circumstances; the use of complementary strategies; and collaboration between
provider institutions and organizations aimed at improving quality.  Quality
improvement efforts resulting in error reduction, enhanced patient safety,
improvements in appropriateness, service enhancements, and waste reduction are
plausible solutions to provide Americans with high quality care at reasonable
cost (Berwick, 1998).  A first step in this process to harness the potential of
quality improvement is a rigorous analysis of improvement strategies to build a
fundamental "basic science" understanding of the relative merits of these
strategies.  That understanding will foster the appropriate application of
quality improvement techniques in the future.

Despite gains which have occurred in the overall health of Americans, significant
disparities persist in the burden of illness and death experienced by racial and
ethnic minority populations.  The health of these groups increasingly will affect
the health of the entire nation because of their projected growth as a proportion
of the U.S. population.  The challenge of improving the health of the nation
increasingly is becoming the challenge of eliminating health disparities
experienced by these populations.  One purpose of this solicitation is to focus
on research projects in racial/ethnic minority populations which assess quality
of care improvement strategies for one or more of the six conditions (infant
mortality, cancer screening and management, cardiovascular disease, diabetes, HIV
infection, and child and adult immunization) identified in the President's Race
and Health Disparities Initiative.  Quality improvement strategies evaluated
through this solicitation will support the Initiative by providing proven
approaches to improving health care in minority communities.

Scope and Objectives

This RFA seeks applications for studies that compare the effectiveness of current
efforts within organized systems of quality improvement to generate the
information needed to guide future investments in quality improvement by health
care systems and policymakers.

Methods

Applicants are expected to develop working partnerships between existing health
care quality improvement efforts through established mechanisms (such as Peer
Review Organizations (PROs), Quality Improvement Organizations (QIOs),
accrediting bodies, large purchasers, and health plans) and academic researchers. 
These consortia will facilitate access to the relevant data, resources, and
expertise to conduct analyses evaluating a range of quality improvement
strategies across multiple health care organizations and integrated delivery
systems.  AHCPR encourages the meaningful inclusion of minority institutions in
these working partnerships.

Disease conditions which are targeted by the quality improvement interventions
being compared should be those with high prevalence (or of high importance to
subsets of the populations, e.g. children or chronically ill), clear association
of outcomes with quality of care, ease of assessment with existing valid and
reliable quality measures, potential measurable improvement within a 2-year time
frame, and availability of patient data.  Aggregations of conditions might be
selected for study if the data are adequate and methodologies are sound,
particularly if they represent problem areas for special populations such as
children, women, minority populations, the elderly, or those with chronic
disease. Applications comparing interventions which address conditions which are
the focus of existing quality improvement efforts through HCFA sponsored Peer
Review Organizations, Quality Improvement Organizations, purchaser groups, health
plans, the President's Race and Health Disparities Initiative, and similar
entities are highly encouraged. Processes of care which could be targeted for
improvement include preventive measures, diagnostic tests, counseling,
treatments, and other patient care activities which have been validated against
important patient outcomes.

In addition to process and outcomes focused quality measures, applicants are
encouraged to consider using a systems approach to error reduction as a vehicle
for investigating the utilities of various improvement strategies.  Strategies
using information technologies to provide information to providers which assist
in improving the quality of care are encouraged.  These include electronic
patient records; automated prompts, alerts, and reminders; and automated access
to clinical practice guidelines and performance measures.  Information technology
strategies may be evaluated for their abilities to reduce medical errors and
support other tools that are useful for improving the quality of patient care.

Applicants must use valid and reliable quality measures and should consider using
quality measures and patient assessment questions organized or developed by AHCPR
programs (including, but not limited to quality measures in the CONQUEST database
and the Consumer Assessment of Health Plans), but not to the exclusion of other
existing reliable and valid measures that may be highly valuable.

Strategies to improve quality to be assessed and compared can be selected from
among the range of currently employed improvement efforts including but not
limited to:

o  continuous quality improvement
o  the use of regulations
o  focused incentives
o  behavioral interventions
o  academic detailing
o  educational interventions
o  the use of information systems

A key consideration in the review of applications will be the ability of the
proposed project to compare interventions which have a measurable impact on
health care quality.  Applicants should carefully outline their plans to capture
the impact of interventions they wish to compare through the collection of
quality measures and outline a strategy for determining whether a lack of impact
was due to a failure of the intervention or other factors.  Any substantial
change in the features of the intervention during the course of observation
should be noted and examined for its independent contribution to any change in
quality measures.  Attrition from the sample should be examined for any
connection with quality of care.

Applications comparing interventions which were subject to experimental designs,
prospective collection of data, and rigorous collection of potentially mediating
variables are encouraged.  An alternative to prospective designs would be
retrospective collection of the quality measures in the population under study
for 6-12 months prior to the beginning of an intervention (changes in outcomes
may take a longer period of time). After the intervention begins, these measures
should be assessed at least annually.  These measurement strategies may be a part
of ongoing activities of the partners in these projects, such as Peer Review
Organizations, Quality Improvement Organizations, purchaser groups, health plans,
and other quality improvement entities.

The means for collecting information on the features of each improvement
strategy, its impact on the quality measures, and the size and characteristics
of the population affected should be described carefully.  In addition, the
methods for capturing the costs of the improvement strategy, including those
associated with development, implementation, and maintenance of the effort should
be documented. The framework for comparing strategies incorporating both
effectiveness and cost analyses should be described in detail.

Applicants should assess the generalizability resulting from their choice of
strategies, geographic areas, delivery systems, and providers and patients for
study.  Applicants should consider how they might maximize the generalizability
of their findings across organizational settings and conditions.  Two examples
of ways to advance this goal would be (a) research consortia incorporating
multiple intervention sites and (b) studies that focus on two or more conditions. 
Applications which evaluate quality improvement strategies across a variety of
settings including inpatient care, outpatient/ambulatory care, and long term care
as well as across geographic regions and different types of facility ownerships
such as government, nonprofit, and for-profit entities are desirable.

Applications should include a detailed plan outlining the dissemination strategy
for any results from the project, including specific plans to promote the
adoption of successful improvement strategies in non-study organizations and
settings.

SPECIAL REQUIREMENTS

Collaborative Activities Among Awardees

Collaborative activities are intended to strengthen individual studies and at the
same time generate generalizable results across multiple study sites, projects,
disease conditions, and patient and physician groups. To maximize the utility and
generalizability of work under this RFA, awardees will be expected to participate
in meetings with other grantees and AHCPR staff 3 times per year.  Investigators
will be encouraged to participate in collaborative work as developed in these
meetings that promote commonality of research methods, shared measures of impact,
and generalizability.  These collaborative activities may include a focus on the
generic characteristics of intervention strategies, institutions, and
populations, which lead to measurable quality improvement.  In addition, the
collaborative activities may be used to promote comparability of data elements
across projects, evaluate the cost-effectiveness of various strategies, and
examine the sustainability and portability of the improvement strategies.

Documentation of Partnership Arrangements

Applicants are required to have working partnerships with existing health care
quality improvement efforts through established mechanisms such as Peer Review
Organizations (PROs), Quality Improvement Organizations (QIOs), accrediting
bodies, large purchasers, health plans, and academic researchers.  Documentation
of the partnership(s), such as letters of collaboration or copies of memoranda
of understanding, must be submitted in the application package.

Conditions of Award

In addition to other applicable grants policies and requirements, the following
conditions apply to all AHCPR grant awards. Applicants should also be familiar
with the Agency's grant regulation, 42 CFR Part 67, Subpart A, and particularly
sections 67.18-67.22.

Data Privacy

Information obtained in the course of AHCPR-supported projects that identifies
an individual or entity must be treated as confidential in accordance with
section 903(c) of the Public Health Service Act.  Applicants must describe in the
Human Subjects section of the application procedures for ensuring the
confidentiality of identifying information.  The description of the procedures
should include a discussion of who will be permitted access to the information,
both raw data and machine readable files, and how personal identifiers will be
safeguarded.

Rights in Data

AHCPR grantees may copyright or seek patents, as appropriate, for final and
interim products and materials including, but not limited to, methodologic tools,
measures, software with documentation, literature searches, and analyses, which
are developed in whole or in part with AHCPR funds. Such copyrights and patents
are subject to a Federal Government license to use and permit others to use these
products and materials for AHCPR purposes. In accordance with its legislative
dissemination mandate, AHCPR purposes may include, subject to statutory
confidentiality protections, making research materials, databases, and algorithms
available for verification or replication by other researchers; and subject to
AHCPR budget constraints, final products may be made available to the health care
community and the public by AHCPR, or its agents, if such distribution would
significantly increase access to a product and thereby produce public health
benefits. Ordinarily, to accomplish distribution, AHCPR publicizes research
findings but relies on grantees to publish in peer-reviewed journals and to
market grant-supported products.

INCLUSION OF WOMEN, MINORITIES, AND CHILDREN IN RESEARCH STUDY POPULATIONS
INVOLVING HUMAN SUBJECTS

It is the policy of AHCPR that women and members of minority groups be included
in all AHCPR-supported research projects involving human subjects, unless a clear
and compelling rationale and justification are provided that inclusion is
inappropriate with respect to the health of the subjects or the purpose of the
research.

All investigators proposing research involving human subjects should read the
"NIH Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical
Research," published in the Federal Register of March 28, 1994 (FR 59
14508-14513), and in the NIH Guide for Grants and Contracts of March 18, 1994. 
AHCPR follows the NIH Guidelines, as applicable.

AHCPR also encourages investigators to consider including children in study
populations, as appropriate. AHCPR announced in the NIH Guide for Grants and
Contracts, May 9, 1997, that it is developing a policy and implementation plan
on the inclusion of children in health services research.  This notice is
available through AHCPR's Web site http://www.ahcpr.gov/ (Funding Opportunities)
and InstantFAX (see instructions under INQUIRIES).  Applicants may obtain copies
from the above sources or from the AHCPR contractor, Equals Three Communications,
Inc., listed under INQUIRIES.  AHCPR program staff may also provide information
concerning these policies (see INQUIRIES).

LETTER OF INTENT

Prospective applicants are asked to submit, by March 1, 1999, a letter of intent
that includes the names, addresses, and telephone numbers of the proposed
Principal Investigator and other key personnel; the identities of proposed
consortia members, including any other participating organizations or
institutions; a descriptive title of the proposed project; and the number and
title of this RFA.

Although a letter of intent is not required, is not binding, and does not enter
into the consideration of any subsequent application, the information allows
AHCPR to estimate the potential review workload and avoid conflicts of interest
in the review.  AHCPR will not provide responses to letters of intent.

The letter of intent is to be sent to the Project Officer at the address listed
under INQUIRIES.

APPLICATION PROCEDURES

Applicants should use the research grant application form PHS 398 (rev. 4/98) in
applying for these grants.  State and local government applicants may use form
PHS-5161-1, "Application for Federal Assistance" (rev. 5/96), and follow those
requirements for copy submission.  Application kits are available at most
institutional offices of sponsored research and may also be obtained from the
Division of Extramural Outreach and Information Resources, National Institutes
of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone
301/435-0714, Email: grantsinfo@nih.gov.

AHCPR applicants are encouraged to obtain application materials from the AHCPR
contractor: Equals Three Communications, Inc., 7910 Woodmont Avenue, Suite 200,
Bethesda, MD 20814-3015; telephone 301/656-3100 or FAX 301/652-5264.

The RFA label available in the form PHS 398 (rev. 4/98) must be affixed to the
bottom of the face page of the original application.  Failure to do so could
result in delayed processing of the application such that it may not reach the
review committee in time for review.  In addition, the RFA title and number must
be typed on line 2 of the face page of the application form, and the YES box must
be marked.

The PHS 398 type size requirements will be rigorously enforced and non-compliant
applications will be returned.

Submit a signed, typewritten original of the application, including the
Checklist, and three signed photocopies, in one package to:

CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040, MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for express/courier service)

Applications submitted under this RFA must be received in the Center for
Scientific Review, NIH, by April 22, 1999.  If an application is received after
that date it will be returned to the applicant without review.

At the time of submission, two additional copies of the application must also be
sent to:

Lisa Krever
Center for Quality Measurement and Improvement
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 502
Rockville, MD  20852-4908

Application Preparation

Applicants are reminded to refer to the sections on "Methods" under RESEARCH
OBJECTIVES and SPECIAL REQUIREMENTS in preparing their applications.

For Use of HCFA Data:  For applications that propose to use Medicare or Medicaid
data that are individually identifiable, applicants should state explicitly in
the "Research Design and Methods" section of the Research Plan (for PHS 398) the
specific files, time periods, and cohorts proposed for the research.  In
consultation with the Health Care Financing Administration (HCFA), AHCPR will use
this information to develop a cost estimate for obtaining the data.  This
estimate will be included in the estimated total cost of the grant at the time
funding decisions are made.

Applicants should be aware that for individually identifiable Medicare and
Medicaid data, Principal Investigators and their grantee institutions will be
required to enter into a Data Use Agreement (DUA) with HCFA to protect the
confidentiality of data in accordance with OMB circular A-130, Appendix III -
Security of Federal Automated Information Systems.  The use of the data is
restricted to the purposes and time period specified in the DUA.  At the end of
this time period, the grantee is required to return the data to HCFA or certify
that the data has been destroyed.  Grantees must also comply with the
confidentiality requirements of Section 903(c) of the PHS Act.

Budget Preparation

The following guidance will supplement the standard requirements in form PHS 398
(rev. 4/98).

-  The costs of clinical care provided to participants in any project will not
be paid out of grant funds.

-  Budgets should reflect travel by the Principal Investigator to attend a total
of 3 one-day meetings per year of the grantees for the collaborative work
outlined above.  These meetings will generally take place in the Washington,
DC/Baltimore, MD area. It is anticipated that most other collaborative work can
be conducted by teleconferencing and e-mail channels.

-  Budgets may also reflect other costs associated with the collaborative nature
of these projects including consortia costs for partners, data translation and
management costs, and travel costs for additional meetings with other grantees.

REVIEW CONSIDERATIONS

Applications will be reviewed for completeness by the CSR and for responsiveness
by AHCPR.  Applications that are complete and responsive to the RFA will be
evaluated for scientific and technical merit by an appropriate peer review group
convened in accordance with AHCPR peer review procedures. As part of the merit
review, all applications will receive a written critique, and also may undergo
a process in which only those applications deemed to have the highest scientific
merit will be discussed and assigned a priority score.  If the application is not
responsive to the RFA, AHCPR referral staff may contact the applicant to
determine whether to return the application to the applicant or submit it for
review in competition with unsolicited applications at the next review cycle.

General Review Criteria

The general review criteria for AHCPR applications are: significance and
originality from a scientific and technical viewpoint; adequacy of the method(s);
availability of data or a proposed plan to collect data required for the project;
adequacy of the plan for organizing and carrying out the project; qualifications
and experience of the Principal Investigator and proposed staff; reasonableness
of the proposed budget; adequacy of the facilities and resources available to the
applicant; the extent to which women, minorities, and children (as appropriate)
and where applicable, are adequately represented in study populations; and the
adequacy of the proposed means for protecting human subjects.

Special Review Criteria

In addition to the general criteria above, the reviewers will assess the
application's responsiveness to the RFA and other critical aspects such as:

-  the extent to which partners in the project contribute human and financial
resources to the effort;

- demonstrated/evidence of ability to develop working partnerships between
academic and health care quality improvement organizations;

-  access to relevant data on patient care as evidenced by letters of commitment
from any organization supplying data;

- use of existing valid and reliable quality measures;

-  development of applications incorporating multiple sites and a variety of
quality improvement strategies which can be compared under this RFA;

- demonstrated ability to generalize findings for each improvement strategy and
their relative utility;

- ability of the proposed project to measure the impact of the intervention(s);

- demonstrated/evidence of ability to conduct comparative and economic analyses
of health care quality improvement interventions;

- development of a dissemination strategy for any results from the project,
including specific plans to promote the adoption of successful improvement
strategies in non-study organizations and settings;

-  demonstrated ability to engage in collaborative work with outside scientists;

- commitment to working on collaborative activities with other researchers funded
under this RFA.

Additional Review Criteria for Set-aside Funds:

Applicants for set-aside funds should explicitly note their intent to have the
application considered for those funds.  In addition to the review criteria
above, these applications will be evaluated on the following criteria:

1. The significance of the project in addressing one or more of the six
conditions identified in the President's Race and Health Disparities Initiative
(infant mortality, cancer screening and management, cardiovascular disease,
diabetes, HIV infection, and child and adult immunization) in one or more of the
four identified racial/ethnic minority population groups (Black, Hispanic,
American Indian and Alaska Native, Asian American and Pacific Islander).

2. The degree to which the project demonstrates a meaningful collaboration
between a minority institution and a majority institution.

AWARD CRITERIA

Applications will compete for available funds with all other applications under
this RFA. Applications deemed eligible for set-aside funds will compete with
other eligible applications for set-aside funds, and if not funded, will compete
with all other applications under this RFA.  The following will be considered in
making funding decisions:  quality of the proposed project as determined by peer
review, availability of funds, and program balance with respect to types of
improvement strategies, populations, and conditions being studied.

Special preference will be accorded to applications from investigators not
recently or currently funded as principal investigator of an AHCPR grant for
research on quality improvement strategies.

INQUIRIES

Written and telephone inquiries concerning this RFA are encouraged. Copies of the
RFA are available from:

Equals Three Communications, Inc.
7910 Woodmont Avenue, Suite 200
Bethesda, MD 20814-3015
Telephone:  (301) 656-3100
FAX:  (301) 652-5264

The RFA is available on AHCPR's Web site, http://www.ahcpr.gov (Funding
Opportunities) and through AHCPR InstantFAX at 301/594-2800.  To use InstantFAX,
you must call from a facsimile (FAX) machine with a telephone handset. Follow the
voice prompt to obtain a copy of the table of contents, which has the document
order number (not the same as the RFA number).

The RFA will be sent at the end of the ordering process.  AHCPR InstantFAX
operates 24 hours a day, 7 days a week.  For questions about this service, call
Judy Wilcox, Office of Health Care Information at 301/594-1364 ext. 1389.

AHCPR welcomes the opportunity to clarify any issues or questions from potential
applicants.  Written and telephone inquiries concerning this RFA are encouraged.
Direct inquiries regarding programmatic issues, including information on the
inclusion of women, minorities, and children in study populations, as well as
additional information about AHCPR supported work pertaining to quality of care,
quality measurement, and the Consumer Assessment of Health Plans to:

Marge Keyes
Center for Quality Measurement and Improvement
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 502
Rockville, MD  20852-4908
Telephone:  (301) 594-1349
Email:  mkeyes@ahcpr.gov

Direct inquiries regarding fiscal matters to:

Al Deal
Grants Management Specialist
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 601
Rockville, MD  20852-4908
Telephone:  (301) 594-1843
FAX:  (301) 594-3210
Email:  adeal@ahcpr.gov

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance Number
93.226.  Awards are made under authorization of Title IX of the Public Health
Service Act (42 U.S.C. 299-299c-6) and section 1142 of the Social Security Act
as applicable.  Awards are administered under the PHS Grants Policy Statement and
Federal regulations 42 CFR 67, Subpart A, and 45 CFR Parts 74 and 92.  This
program is not subject to the intergovernmental review requirements of Executive
Order 12372 or Health Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a
smoke-free workplace and promote the non-use of all tobacco products.  In
addition, Public Law 103-227, The Pro-Children Act of 1994, prohibits smoking in
certain facilities (or in some cases, any portion of a facility) in which regular
or routine education, library, day care, health care, or early childhood
development services are provided to children.  This is consistent with the PHS
mission to protect and advance the physical and mental health of the American
people.

References

Blumenthal D, Kilo CM, 1998.  A Report Card on Continuous Quality Improvement. 
Milbank Quarterly, in press.

Berwick DM, 1998.  As good as it should get:  Making health care better in the
new millenium.  Paper for the National Coalition on Health Care, Washington, DC.

Chassin MR,  1996.  Improving the Quality of Care.  NEJM, 335:1060-3.

Chassin MR, 1997.  Assessing strategies for quality improvement.  Health Affairs,
16:151-61.

Chassin MR, Galvin RW, and the National Roundtable on Health Care Quality.  1998. 
The Urgent Need to Improve Health Care Quality.  JAMA, 280:1000-5.

Evans RS, Pestonik SL, Classen DC, et. al.  A computer-assisted management
program for antibiotics and other anti-infective agents.  NEJM, 338:232-8.

Laffel G; Blumenthal D, 1989.  The case for using industrial quality management
science in health care organizations. JAMA 262:2869-73.

Marciniak TA; Ellerbeck EF; Radford MJ; Kresowik TF; Gold JA; Krumholz HM; Kiefe
CI; Allman RM; Vogel RA; Jencks SF, 1998.  Improving the quality of care for
Medicare patients with acute myocardial infarction: results from the Cooperative
Cardiovascular.  JAMA 279: 1351-7.

President's Advisory Commission on Consumer Protection and Quality in the Health
Care Industry, 1998.  Quality First:  Better Health Care For All Americans. 
Washington, DC:  U.S. Government Printing Office.

Shortell SM, Bennett CL, Byck GR, 1998.  Assessing the impact of continuous
quality improvement on clinical practice:  What it will take to accelerate
progress.  Medical Care, in press.

Soumerai SB; McLaughlin TJ; Gurwitz JH; Guadagnoli E; Hauptman PJ; Borbas C;
Morris N; McLaughlin B; Gao X; Willison DJ; Asinger R; Gobel F, 1998.  Effect of
local medical opinion leaders on quality of care for acute myocardial infarction:
a randomized controlled trial.  JAMA  279:358-63.


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