Part 1. Overview Information
Participating Organization(s)

Agency for Healthcare Research and Quality (AHRQ)

NOTE: The policies, guidelines, terms, and conditions stated in this announcement may differ from those used by the NIH. Where this Funding Opportunity Announcement (FOA) provides specific written guidance that may differ from the general guidance provided in the grant application form, please follow the instructions given in this FOA. Also note that AHRQ may have different page limits than NIH for the application Research Strategy, which can be found within each individual FOA (see Section IV below). AHRQ Grants Policy and Information to applicants regarding Funding Opportunity Announcement procedures can be found at Funding Opportunity Announcement Guidance.

Components of Participating Organizations

Agency for Healthcare Research and Quality (AHRQ)
Center for Quality Improvement and Patient Safety (C-QuIPS)

Funding Opportunity Title

Advances in Patient Safety through Simulation Research (R18)

Activity Code

R18 Research Demonstration and Disseminations Projects

Announcement Type

Reissue of PAR-11-024

Related Notices
  • September 29, 2016 - AHRQ Extends Expiration Date for PA-14-004. See Notice NOT-HS-16-021.
  • September 6, 2016 - This PA has been reissued as PA-16-420.
  • NOT-OD-16-004 - NIH & AHRQ Announce Upcoming Changes to Policies, Instructions and Forms for 2016 Grant Applications (November 18, 2015)
  • NOT-OD-16-006 - Simplification of the Vertebrate Animals Section of NIH Grant Applications and Contract Proposals (November 18, 2015)
  • NOT-OD-16-011 - Implementing Rigor and Transparency in NIH & AHRQ Research Grant Applications (November 18, 2015)
Funding Opportunity Announcement (FOA) Number


Companion Funding Opportunity


Number of Applications

Section III. 3. Additional Information on Eligibility.

Catalog of Federal Domestic Assistance (CFDA) Number(s)


Funding Opportunity Purpose

The Agency for Healthcare Research and Quality (AHRQ) is interested in funding a diverse set of projects that develop, test and evaluate various simulation approaches for the purpose of improving the safe delivery of health care. Simulation in health care serves multiple purposes. As a training technique, it exposes individuals and teams to realistic clinical challenges through the use of mannequins, task trainers, virtual reality, standardized patients or other forms, and allows participants to experience in real-time the consequences of their decisions and actions. The principal advantage of simulation is that it provides a safe environment for health care practitioners to acquire valuable experience without putting patients at risk. Simulation also can be used as a test-bed to improve clinical processes and to identify failure modes or other areas of concern in new procedures and technologies that might otherwise be unanticipated and serve as threats to patient safety. Yet another application of simulation focuses on the establishment of valid and reliable measures of clinical performance competency and their potential use for credentialing and certification purposes. Applications that address a variety of simulation techniques, clinical settings, provider groups, priority populations, patient conditions, and threats to safety are welcomed.

Key Dates
Posted Date

November 21, 2013

Open Date (Earliest Submission Date)

December 25, 2013

Letter of Intent Due Date(s)

Not Applicable

Application Due Date(s)

Standard dates apply, by 5:00 PM local time of applicant organization.

Applicants are encouraged to apply early to allow adequate time to make any corrections to errors found in the application during the submission process by the due date. Of the two choices, keep only the applicable one. Date is expected to be three months (minimum two months) after publication of the announcement (assume 30 days in one month).

AIDS Application Due Date(s)

Not Applicable

Scientific Merit Review

Generally, four months after receipt date

Advisory Council Review

Not Applicable

Earliest Start Date

Generally, four months after peer review date

Expiration Date

New Date October 12, 2016 per issuance of NOT-HS-16-021. (Original Expiration Date: September 6, 2016 )

New Date September 6, 2016 per issuance of PA-16-420. (Original Expiration Date: September 26, 2016)

Due Dates for E.O. 12372

Not Applicable

Required Application Instructions

It is critical that applicants follow the instructions in the SF424 (R&R) Application Guide, except where instructed to do otherwise (in this FOA or in a Notice from the NIH Guide for Grants and Contracts). Conformance to all requirements (both in the Application Guide and the FOA) is required and strictly enforced. Applicants must read and follow all application instructions in the Application Guide as well as any program-specific instructions noted in Section IV. When the program-specific instructions deviate from those in the Application Guide, follow the program-specific instructions. Applications that do not comply with these instructions may be delayed or not accepted for review.

Table of Contents

Part 1. Overview Information
Part 2. Full Text of the Announcement
Section I. Funding Opportunity Description
Section II. Award Information
Section III. Eligibility Information
Section IV. Application and Submission Information
Section V. Application Review Information
Section VI. Award Administration Information
Section VII. Agency Contacts
Section VIII. Other Information

Part 2. Full Text of Announcement

Section I. Funding Opportunity Description

Research Objectives

The Agency for Healthcare Research and Quality (AHRQ) announces the availability of grants to develop, test, and evaluate the impact of various simulation approaches for the purpose of improving the safe delivery of health care. As a training technique, simulation in health care uses a variety of approaches mannequins, task trainers, virtual reality, in situ scenarios, hybrid configurations, standardized patients to expose individuals and teams to realistic clinical challenges. A distinguishing feature of simulation is that it allows participants to experience, in real- or near real-time, the consequences of their decisions and actions as they learn new skills and address system anomalies in an environment that does not put patients at risk. Simulation also can be used as a test-bed to identify failure modes and other areas of concern in new clinical processes, procedures, and technologies that might threaten patient safety. Another use of simulation is as a vehicle to help establish performance competency benchmarks of interest to credentialing and certification initiatives. AHRQ is seeking applications that address a variety of clinical settings. The projects funded under this funding opportunity announcement (FOA) will inform providers, health educators, payers, policy makers, AHRQ, patients, and the public about the effective use of simulation in improving patient safety.

Applicant institutions are required to describe the simulation, including the expected impact on patient safety outcomes; provide a project design and methodology plan that covers development, test and evaluation activities; specify the simulation methods, equipment, and resources that will be utilized; outline how the simulation will be implemented in the proposed health care setting; describe the metrics to be used to indicate acceptable performance; provide a data analysis and evaluation plan, and address the projected dissemination, adoption, and sustainability issues associated with the particular simulation approach used.

AHRQ encourages a variety of simulation projects from across the health care spectrum which impact diverse patient populations, including priority populations, provider groups, and clinical settings. Priority populations include: low income groups; minority groups; women; children; the elderly; and individuals with special health care needs, including individuals with disabilities and individuals who need chronic care or end-of-life health care. Diverse settings of care and venues for simulation might include, but are not limited to, hospitals, ambulatory surgery centers, primary care clinics, medical centers, schools of nursing, universities, community colleges, health care provider organizations, health systems, health professional associations, and quality and safety improvement organizations. Projects presented for consideration under this FOA should comply with the Agency s policy regarding the inclusion of priority populations (see AHRQ Notice, as well as further information below in the special requirements section of this FOA.

AHRQ’s Role in Patient Safety

In its release of To Err is Human: Building a Safer Health System in November 1999, the Institute of Medicine (IOM) estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. The IOM report quickly elevated awareness of patient safety. One of the major take-home messages was that preventable adverse events arise from problems inherent in a complex and fragmented health care system that providers inherit. Although the United States provides some of the best health care in the world, it isn t evenly distributed throughout the nation, and the number of patients that are harmed as a result of the process of health care is unacceptably high. The report called for systematic change in health care practice, and cited safety improvements made in other hazardous industries through the use of error reporting systems, information technology, human factors considerations, process redesign, simulation and teamwork, and cultures of open communication and learning.

AHRQ was subsequently directed to lead a national effort to improve patient safety through appropriately targeted research. The initial patient safety grants focused on reporting systems, clinical informatics, the working conditions of providers, Centers of Excellence for multiple, programmatic projects, Developing Centers for new researchers, and education and dissemination efforts. Since these early beginnings, patient safety has continued to be a major portfolio area of AHRQ. A fuller and more detailed account of other patient safety initiatives and activities can be found on AHRQ’s Web site at

Simulation Overview

While simulation in health care can be traced to the 1960s with Resusci-Anne used for cardiopulmonary resuscitation (CPR) training, it was not until the late 1980s that pioneering research efforts started to take hold in anesthesiology with the development of simulation systems that trained participants in clinical management and teamwork.

Traditionally, the education of providers has focused on knowledge acquisition rather than the acquisition of defined levels of acceptable clinical performance. At the same time, it is recognized that many health care procedures are potentially dangerous and very difficult to teach and learn. A troubling paradox of health care delivery is that today's patients can be harmed in the training of tomorrow's practitioners. The apprenticeship expression of "see one, do one, teach one" has been reframed as "see one, do many with simulation, teach one" by adopters of simulation techniques. It is increasingly recognized that the education and training of providers is a life-long process, especially as new technology and less invasive procedures make their way into clinical practice. It is reasonable to expect that simulation's benefits accrue not only to inexperienced and vulnerable health care workers at the start of their careers, but also to experienced practitioners learning new procedures.

In addition to their promising potential of reducing risk to patients, simulations are valued for their ability to create conditions that optimize learning. Limited performance repertoires of novices and practitioners learning new procedures can be expanded with a graduated crawl-walk-run approach. Intricate elements of a difficult procedure can be selectively rehearsed again and again. Simulations can be programmed to provide training on patient complications and equipment malfunctions that occur infrequently in practice, but that require decisive action and skilled performance when they do occur. Simulations enable a complex mosaic of multiple skills cognitive, perceptual-motor, and affective to be simultaneously exercised. When fluid team performance is the goal, simulations provide a venue for technical skills, decision-making, communication and leadership skills to be exercised together.

In contrast to training-based applications, simulations also can serve as evaluation and usability test-beds to work out the unanticipated wrinkles of new emerging technologies and design features of facilities. Changes to the clinical workflow and potential threats to patient safety can be identified as new point-of-care systems and design features are modeled and tested in a simulated environment.

Within the past decade, there has been a progressively increasing interest in a broad array of simulation applications to health care. Advances in medical simulation technology, a progressive lowering of associated costs, a national focus on patient safety, greater recognition of the performance-based component of clinical competency, shortening of hours for residents thereby reducing exposure to less common procedures, and a greater willingness to incorporate lessons learned from other high-risk industries are a few of the factors that help to account for this heightened interest. Other indicators of the heightened interest can be found in the impressive growth of simulation centers in medical and nursing schools, and the Society for Simulation in Healthcare with its own journal and well attended annual conferences. It also is noteworthy that the Accreditation Council for Graduate Medical Education (ACGME), the governing body for post-graduate medical education in the US, has been examining the curriculum inclusion of simulation in helping to satisfy the six competencies (i.e., patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice).

AHRQ-Funded Simulation Grants

In fiscal years 2006 and 2007 AHRQ awarded approximately $10 million to advance knowledge of how simulation can improve patient safety across diverse healthcare disciplines, settings and populations. The grants were 2-year cooperative agreements and covered a diverse range of simulated clinical applications. Representative of the diversity were simulations that focused on central venous catheter insertion, diagnosis of melanoma, obstetric emergency response drills, pediatric airway management, rapid response teams, acute coronary syndrome management in rural settings, patient care hand-offs, virtual reality team training, and disclosure of medical error. In 2008, AHRQ, along with other organizations, supported an academic emergency medicine consensus conference that was organized to help define a national research agenda for maximizing effective use of simulation across undergraduate, graduate, and continuous medical education. In 2011, AHRQ funded 11 more multi-year demonstration grants to evaluate the use and effectiveness of various simulation approaches in another set of diverse care settings (e.g., cardiac surgery, pathology diagnosis, recognition of sepsis, pediatric resuscitation, leadership and emergency team performance, usability testing of rapid-prototype infusion pump designs, measuring characteristics of laparoscopic skill, and using simulation for teaching femoral arterial access). In November 2011, AHRQ released another multi-year FOA, titled 'Advances in Patient Safety through Simulation Research', as its continuing funding vehicle for simulation research.

To make the same advances in healthcare with simulation that other hazardous industries have made will take a continuing programmatic effort. A vast number of research challenges remain that need to be addressed for simulation in healthcare to reach its full potential. The current FOA is an effort to support projects that will respond to these challenges on a steady and on-going basis. Provided below is a partial list of research challenges, questions, and issues to stimulate thinking and ideas about potential projects. It by no means exhausts the range of simulation issues that are of interest to AHRQ; thus, applications addressing relevant simulation and patient safety challenges not stated below are also welcomed.

Technical Skills

What are the core individual skills or competencies within or across key provider groups likely to have patient safety impact and that have potential to be enhanced with different forms of simulation?

What are the appropriate performance measures for crucial nursing, medical and surgical procedures?

How are acceptable levels of individual performance established for particular procedures or processes? Can criterion levels be established for different levels of proficiency -- novice, intermediate, and expert?

How much variation among trainees is there with respect to rate of skill acquisition and performance levels achieved? Does simulation help to reduce the variation?

What does skilled performance look like as fixed periods of time elapse in the absence of practice? Are certain dimensions of skilled performance more subject to skill decay with the passage of time than others?

How much simulation retraining is needed to restore decayed performance to an earlier established level of proficiency? For intricate, risky procedures, can simulation performance criteria be established to assess readiness for performing such procedures on actual patients?

Team Performance

What are the core team skills or competencies of key provider groups that can be enhanced with simulation and that are linked to patient outcomes? Are additional team skills and competencies required for addressing the needs of patients with disabilities or less commonly encountered health care issues?

What are the appropriate performance measures for individuals within teams and for collective team performance when the team is the aggregated unit for measurement and analysis?

Are there distinguishing differences between ad hoc teams versus fixed teams with respect to team performance levels achieved and retained?

How can simulations be used to enhance the resilient and adaptive capacity of teams in responding to the unexpected in different care settings?

How can simulations be used to foster a shared mental model given the fluid, dynamic and distributed nature of clinical work with its multiple ad hoc agents?

System Performance

Can simulations be used to help health care entities achieve greater improvements and system-wide effects by addressing related patient safety harms? Can scenarios be created that exercise a continuity of safety across the transitions of the patient care experience and not just the individual components?

Can simulation or modeling techniques be used to assess how hospitals can satisfy simultaneous demands for patient safety, worker safety, efficiency, disaster/surge capacity, and environmental sustainability?

How can simulations be used as evaluation or usability test-beds for medical devices, new technology, and facility design features to assess potential adverse impacts on patient safety and quality of care?

Can simulations be used as a "check-out" procedure (similar to the "check ride" used for newly minted aviators) to ensure clinician proficiency in the safe use, operation, and maintenance of the new system?

Are there promising applications of simulation to new frontiers of patient safety such as the challenges associated with diagnostic performance and its improvement? Can scenarios be created that require diagnosticians to process the same incomplete patient information while subject to the same constraints, interruptions and time pressures, make the same decisions, and take the same actions with patients experiencing the same consequences as would occur in a clinical setting?

Methodological Issues

What types of simulation and methodological approaches stand the best chance of demonstrating a convincing link between performance in the simulation and patient safety outcomes?

Are there agreed-upon nomenclatures, taxonomies, and metrics for the tasks, skills, and procedures that make up different provider specialty areas to guide and aggregate research findings?

What are the metrics and designs for demonstrating positive transfer to training to the clinical setting? Are the metrics and designs sensitive to negative transfer of training as well?

Can experiences and assignments in the clinical setting be used to augment and further reinforce the knowledge and skills acquired in the simulated setting?

How should concerns relating to variable patient acuity, complexity or less commonly encountered special needs be factored into designs and metrics?

What are the advantages, limitations, or unique features associated with part-task trainers, mannequin-based simulation, virtual reality, in situ techniques, hybrid configurations, moulage preparations, standardized patients, crises resource management, serious gaming, and other forms of simulation with respect to impact on effectiveness?

Educational and Training Issues

What are the analyses or methods used to identify difficult tasks, clinical areas of vulnerability, or performance deficiencies for which simulation is appropriate?

Is it possible to assign tasks to computer-based or web-based trainers, part-task trainers, and simulators in an integrated or step-wise approach to achieve greater educational efficiencies and effectiveness?

How does one maximize the total learning experience and not just the simulation experience? Are there principles from other disciplines (e.g., the psychology of learning, instructional systems design, cognitive work analysis, and adult learning theory) that can be adapted and put to good use?

Are there educational strategies that can be used to solidify and further reinforce what has been learned during and after the debriefing to promote new and continued learning?

What types of performance records need to be kept on individuals or teams to track performance levels achieved and for appropriate assignment to more advanced levels of training and simulation?

Accreditation and Certification

How can simulation be used reliably by entities responsible for accreditation of clinical programs and certification of specialists to ensure that standards, knowledge, and skills are maintained at the highest levels of quality and safety?

What assessment methods and criterion levels of competency are most appropriate for the different clinical specialty areas?

What are the assessment and other challenges in the use of simulation during examinations involving high stake decisions (e.g., certification and licensure)?

How can simulation experiences be used to help ensure that residents are exposed to a necessary and sufficient diversity of clinical challenges during their rotations?

How can simulation be used to ensure that veteran practitioners learning new procedures and technologies (e.g., robotic techniques) are qualified in their use and do not put patients at increased risk?

See Section VIII, Other Information - Required Federal Citations, for policies related to this announcement.

Section II. Award Information
Funding Instrument

Grant: A support mechanism providing money, property, or both to an eligible entity to carry out an approved project or activity.

Application Types Allowed


The OER Glossary and the SF424 (R&R) Application Guide provide details on these application types.

Funds Available and Anticipated Number of Awards

Awards issued under this FOA are contingent upon the availability of funds and the submission of a sufficient number of meritorious applications. Because the nature and scope of the proposed research will vary from application to application, it is anticipated that the size and duration of each award will also vary. The total amount awarded and the number of awards will depend upon the number, quality, duration, and costs of the applications received.

Award Budget

Applications may be up to 36 months in duration with a budget supported by AHRQ not to exceed $250,000 total costs in any given year. An application with a budget that exceeds $250,000 total costs in any given year or 36 months in duration will not undergo peer review. Funding beyond the first year will be contingent upon a review and acceptance by Agency staff of the annual progress report.

Award Project Period

The project period may not exceed 36 months.

These projects are being funded pursuant to 42 U.S.C. 299a, which provides that AHRQ shall conduct and support research, support demonstration projects, and disseminate information on health care and on systems for the delivery of such care, including activities with respect to the quality, effectiveness, efficiency, appropriateness, and value of health care services.

All applications submitted and AHRQ grants made in response to this FOA are subject to AHRQ's grant regulations at 42 CFR Part 67, Subpart A, the HHS Grants Policy Statement (see and, and the terms and conditions set forth in the Notice of Award.

Section III. Eligibility Information

1. Eligible Applicants

Eligible Organizations

You may submit an application(s) if your institution/organization is a (an):

AHRQ’s authorizing legislation does not allow for-profit organizations to be eligible to lead applications under this research mechanism. For-profit organizations may participate in projects as members of consortia or as subcontractors only. Because the purpose of this program is to improve healthcare in the United States, foreign institutions may participate in projects as members of consortia or as subcontractors only. Applications submitted by for-profit organizations or foreign institutions will not be reviewed. Organizations described in section 501(c) 4 of the Internal Revenue Code that engage in lobbying are not eligible.

HHS grants policy requires that the grant recipient perform a substantive role in the conduct of the planned project or program activity and not merely serve as a conduit of funds to another party or parties. If consortium/contractual activities represent a significant portion of the overall project, the applicant must justify why the applicant organization, rather than the party(s) performing this portion of the overall project, should be the grantee and what substantive role the applicant organization will play. Justification can be provided in the Specific Aims or Research Strategy section of the PHS398 Research Plan Component sections of the SF424 (R&R) application. There is no budget allocation guideline for determining substantial involvement; determination of substantial involvement is based on a review of the primary project activities for which grant support is provided and the organization(s) that will be performing those activities.

Foreign Institutions

Non-domestic (non-U.S.) Entities (Foreign Institutions) are not eligible to apply.

Required Registrations

Applicant Organizations

Applicant organizations must complete and maintain the following registrations as described in the SF 424 (R&R) Application Guide to be eligible to apply for or receive an award. All registrations must be completed prior to the application being submitted. Registration can take 6 weeks or more, so applicants should begin the registration process as soon as possible. The NIH Policy on Late Submission of Grant Applications states that failure to complete registrations in advance of a due date is not a valid reason for a late submission.

Program Director/Principal Investigator (PD/PI)

The PD/PI must have an eRA Commons account and should work with his/her organizational officials to either create a new account or to affiliate an existing account with the applicant organization’s eRA Commons account. If the PD/PI is also the organizational Signing Official, they must have two distinct eRA Commons accounts, one for each role. Obtaining an eRA Commons account can take up to 2 weeks.

Eligible Individuals (Program Director/Principal Investigator)

Any individual(s) with the skills, knowledge, and resources necessary to carry out the proposed research as the Program Director/Principal Investigator (PD/PI) is invited to work with his/her organization to develop an application for support. Individuals from underrepresented racial and ethnic groups as well as individuals with disabilities are always encouraged to apply for AHRQ support.

Only one PD/PI may be designated on the application.

2. Cost Sharing

This FOA does not require cost sharing.

While there is no cost sharing requirement included in this FOA, AHRQ welcomes applicant institutions, including any collaborating institutions, to devote resources to this effort. An indication of institutional support from the applicant and its collaborators indicates a greater potential of success and sustainability of the project. Examples of institutional support would include: donated equipment and space, institutional funded staff time and effort, or other resource investments. Applicant institutions should indicate institutional support by outlining the specific contributions to the project and providing assurances that their organization and any collaborators are committed to providing these funds and resources to the project. This information can be included at the end of the budget justification section of the application, but institutional support dollars are not to be shown/included in the detailed budget request.

3. Additional Information on Eligibility

Number of Applications

Applicant organizations may submit more than one application, provided that each application is scientifically distinct.

AHRQ will not accept any application that is essentially the same as one already reviewed within the past thirty-seven months, except for submission:

Section IV. Application and Submission Information

1. Requesting an Application Package

Applicants must download the SF424 (R&R) application package associated with this funding opportunity using the Apply for Grant Electronically button in this FOA or following the directions provided at

2. Content and Form of Application Submission

It is critical that applicants follow the instructions in the SF424 (R&R) Application Guide, except where instructed in this funding opportunity announcement to do otherwise. Conformance to the requirements in the Application Guide is required and strictly enforced. Applications that are out of compliance with these instructions may be delayed or not accepted for review.

For information on Application Submission and Receipt, visit Frequently Asked Questions Application Guide, Electronic Submission of Grant Applications.

Letter of Intent

A letter of intent is NOT required for this funding opportunity.

Page Limitations

All page limitations described in the SF424 Application Guide and the Table of Page Limits must be followed.

Required and Optional Components

The forms package associated with this FOA includes all applicable components, required and optional. Please note that some components marked optional in the application package are required for submission of applications for this FOA. Follow all instructions in the SF424 (R&R) Application Guide to ensure you complete all appropriate optional components.

Instructions for Application Submission

The following section supplements the instructions found in the SF424 (R&R) Application Guide and should be used for preparing an application to this FOA.

SF424(R&R) Cover

All instructions in the SF424 (R&R) Application Guide must be followed.

SF424(R&R) Project/Performance Site Locations

All instructions in the SF424 (R&R) Application Guide must be followed.

SF424(R&R) Other Project Information

All instructions in the SF424 (R&R) Application Guide must be followed.

SF424(R&R) Senior/Key Person Profile

All instructions in the SF424 (R&R) Application Guide must be followed.

R&R Budget

All instructions in the SF424 (R&R) Application Guide must be followed, with the following additional instructions:

Budget Component: Special Instructions for AHRQ applications

AHRQ is not using the Modular Grant Application and Award Process. Applicants for funding from AHRQ should ignore application instructions concerning the Modular Grant Application and Award Process, and prepare applications using instructions for the Research and Related Budget Components of the SF 424 (R&R). Applications submitted in the Modular format will not be reviewed.

PHS 398 Cover Page Supplement

All instructions in the SF424 (R&R) Application Guide must be followed.

PHS 398 Research Plan

All instructions in the SF424 (R&R) Application Guide that are not otherwise specified within this Funding Opportunity Announcement must be followed, with the following additional instructions:

Special Application Requirements and Considerations

1. The applicant organization, or at least one partner organization programmatically involved in the project, must be a health care provider organization. The application must specify the chosen simulation and justify its selection.

2. The application should provide supporting evidence as to how the simulation potentially impacts the safe delivery of health care.

3. The application must identify the issues addressed by the simulation, the setting of care where the simulation will be conducted, the health professional groups involved in the simulation, and the anticipated patient population impacted by the simulation.

4. The application must describe in succinct but sufficient detail the patient safety problem to be addressed by the proposed simulation. This could include the relevant literature with respect to the problem area, as well as anticipated benefits, limitations, conceptual frameworks, scientific, clinical or performance-based significance, and underlying assumptions or boundary conditions of the proposed research.

5. The application must provide clear articulation of the research objectives, the methodology or research design that will be enable the research objectives to be realized, and any associated practical considerations. Where appropriate, the application should include specification of outcome measures, process measures, and formative measures for pilot testing, implementation, adoption, and sustainability, where appropriate. Measures that would be of interest to decision- and policy-makers (e.g., return on investment, cost-effectiveness) also should be considered. This section should specify the sampling strategy that identifies the target audience to be sampled, the type of sampling, sample sizes, and any priority populations, conditions, or characteristics that require discussion. The design should include milestones and proposed timelines covering all major phases of the project.

6. The application should describe the functions that the simulation performs and the system components and features that will enable realization of the functions. Where appropriate, the application should describe the clinical, physiological, behavioral, cognitive, visual, auditory, tactile or otherwise unique features that are simulated. Since simulations often make unique demands on the parent organization, the application should describe the full complement of support requirements for effective and efficient deployment of the simulation, such as space and facilities; computer and technical support; specialized equipment; maintenance; and instructors, schedulers, researchers and training development personnel. It is assumed that the applicant institution has sufficient facilities and simulation equipment for the proposed research and that this will preclude the need for acquisition of major equipment or supply items. Applicant institutions may request no more than 15% of Federal grant funds for purchasing equipment, hardware, or software in any given year of the project.

7. As appropriate, the applicant is encouraged to provide a simulation implementation plan which includes the necessary steps, preparations, permissions, approvals, and rehearsals for conducting the simulation. The plan should include information on scenario generation, pilot-testing, scheduling of participants, assignment of participants to groups in accordance with the research design, preparation of materials, orientation of participants, briefing and de-briefing procedures, data collection procedures and instruments, training of personnel and data collectors, and any specialized device, mannequin, or ancillary equipment considerations. The plan should describe quality control procedures for ensuring that all components function well together in achieving a smooth implementation of the simulation.

8. As appropriate, the applicant is encouraged to describe how the data are to be collected, coded, stored, and analyzed in terms of descriptive or inferential methods. Any potential limitations, concerns, or anticipated contingency planning with respect to data collection procedures also should be noted.

9. As appropriate, the applicant is encouraged to describe how the project potentially could be integrated into the mainstream clinical environment. Also applicants should consider discussing what can be learned about necessary resource requirements for effective and efficient deployment of the simulation, as well as its longer term sustainability.

Appendix: Do not use the Appendix to circumvent page limits. Follow all instructions for the Appendix as described in the SF424 (R&R) Application Guide.

Planned Enrollment Report

When conducting clinical research, follow all instructions for completing Planned Enrollment Reports as described in the SF424 (R&R) Application Guide.

PHS 398 Cumulative Inclusion Enrollment Report

When conducting clinical research, follow all instructions for completing Cumulative Inclusion Enrollment Report as described in the SF424 (R&R) Application Guide.

3. Submission Dates and Times

Part I. Overview Information contains information about Key Dates. Applicants are encouraged to submit applications before the due date to ensure they have time to make any application corrections that might be necessary for successful submission.

Organizations must submit applications to (the online portal to find and apply for grants across all Federal agencies). Applicants must then complete the submission process by tracking the status of the application in the eRA Commons, NIH’s electronic system for grants administration. NIH and systems check the application against many of the application instructions upon submission. Errors must be corrected and a changed/corrected application must be submitted to on or before the application due date. If a Changed/Corrected application is submitted after the deadline, the application will be considered late.

Applicants are responsible for viewing their application before the due date in the eRA Commons to ensure accurate and successful submission.

Information on the submission process and a definition of on-time submission are provided in the SF424 (R&R) Application Guide.

4. Intergovernmental Review (E.O. 12372)

This initiative is not subject to intergovernmental review.

5. Funding Restrictions

For efficient grant administration, AHRQ grant administration procedures will be used and conducted in accordance with the terms and conditions, cost principles, and other considerations described in the HHS Grants Policy Statement. The Grants Policy Statement can be found at

Pre-award costs are allowable. A grantee may, at its own risk and without AHRQ prior approval, incur obligations and expenditures to cover costs up to 90 days before the beginning date of the initial budget period of a new award if such costs are necessary to conduct the project and would be allowable under the grant, if awarded, without AHRQ prior approval. If specific expenditures would otherwise require prior approval, the grantee must obtain AHRQ approval before incurring the cost. AHRQ prior approval is required for any costs to be incurred more than 90 days before the beginning date of the initial budget period of a new award.

The incurrence of pre-award costs in anticipation of a competing or non-competing award imposes no obligation on AHRQ either to make the award or to increase the amount of the approved budget if an award is made for less than the amount anticipated and is inadequate to cover the pre-award costs incurred. AHRQ expects the grantee to be fully aware that pre-award costs result in borrowing against future support and that such borrowing must not impair the grantee's ability to accomplish the project objectives in the approved time frame or in any way adversely affect the conduct of the project.

6. Other Submission Requirements and Information

Applications must be submitted electronically following the instructions described in the SF424 (R&R) Application Guide. Paper applications will not be accepted.

Applicants must complete all required registrations before the application due date. Section III. Eligibility Information contains information about registration.

For assistance with your electronic application or for more information on the electronic submission process, visit Applying Electronically.

Important reminders:
The PD/PI must include their eRA Commons ID in the Credential field of the Senior/Key Person Profile Component of the SF424(R&R) Application Package. Failure to register in the Commons and to include a valid PD/PI Commons ID in the credential field will prevent the successful submission of an electronic application to NIH/AHRQ. See Section III of this FOA for information on registration requirements.

The applicant organization must ensure that the DUNS number it provides on the application is the same number used in the organization’s profile in the eRA Commons and for the System for Award Management. Additional information may be found in the SF424 (R&R) Application Guide.

See more tips for avoiding common errors.

Upon receipt, applications will be evaluated for completeness by the Center for Scientific Review, NIH, and for responsiveness by AHRQ. Applications that are incomplete and/or non-responsive will not be reviewed.

In order to expedite the review, applicants are requested to notify the AHRQ Referral Office by email when the application has been submitted. Please include the FOA number and title, PD/PI name, and title of the application.

Institutional Review Board (IRB) approval of human subjects is not required prior to peer review of an application (see However, initiation of IRB review, if necessary or applicable, is strongly encouraged to assure timely commencement of research.

Although there is no immediate acknowledgement of the receipt of an application, applicants are generally notified of the review and funding assignment within eight (8) weeks.

Priority Populations

AHRQ supports research, evaluations, and demonstration projects concerning the delivery of health care in inner-city and rural areas (including frontier areas), and health care for priority populations. Priority populations include low income groups; minority groups; women; children; the elderly; and individuals with special health care needs, including individuals with disabilities and individuals who need chronic care or end-of-life health care. 42 USC 299(c). Women and members of minority groups are included in all AHRQ-supported research projects involving human subjects, unless a clear and compelling rationale and justification is provided that inclusion is inappropriate, e.g. because of the lack of connection between the study and the health of women or particular minorities. Investigators should review the document entitled, AHRQ Policy on the Inclusion of Priority Populations, which is available at Applicants under this FOA should consider and discuss including priority populations in the research design as specified in this Notice.

Plan for Sharing Research Data

The precise content of the data-sharing plan will vary, depending on the data being collected and how the investigator is planning to share the data. Applicants who are planning to share data may wish to describe briefly the expected schedule for data sharing; the format of the final dataset; the documentation to be provided; whether or not any analytic tools also will be provided; whether or not a data-sharing agreement will be required and, if so, a brief description of such an agreement (including the criteria for deciding who can receive the data and whether or not any conditions will be placed on their use); and the mode of data sharing (e.g., under its own auspices by mailing a disk or posting data on its institutional or personal website or through a data archive or enclave). Investigators choosing to share under their own auspices may wish to enter into a data-sharing agreement. References to data sharing may also be appropriate in other sections of the application.

The reasonableness of the data sharing plan or the rationale for not sharing research data will be assessed by the reviewers. However, reviewers will not factor the proposed data sharing plan into the determination of scientific merit or the priority score.

Data Confidentiality

The AHRQ confidentiality statute, 42 USC 299c-3(c), requires that information that is obtained in the course of AHRQ supported activities and that identifies individuals or establishments be used only for the purpose for which it was supplied. Information that is obtained in the course of AHRQ-supported activities and that identifies an individual may be published or released only with the consent of the individual who supplied the information or is described in it. There are civil monetary penalties for violation of the confidentiality provision of the AHRQ statute. 42 USC 299c-3(d). In the Human Subjects section of the application, applicants must describe procedures for ensuring the confidentiality of the identifying information to be collected. The description of the procedures should include a discussion of who will be permitted access to this information, both raw data and machine readable files, and how personal identifiers and other identifying or identifiable data will be restricted and safeguarded. Identifiable patient health information collected by grantees under this FOA will also be obtained and managed in accordance with the HIPAA Privacy Rule, 45 CFR Parts 160 and 164.

The grantee should ensure that computer systems containing confidential data have a level and scope of security that equals or exceeds that established by the HIPAA Security Rules, if applicable, and that established by the Office of Management and Budget (OMB) in OMB Circular No. A-130, Appendix III - Security of Federal Automated Information Systems. The applicability and intended means of applying these confidentiality and security standards to subcontractors and vendors, if any, should be addressed in the application.

Sharing Research Resources: Rights in Data

Unless otherwise provided in grant awards, AHRQ grantees may copyright, or seek patents for, as appropriate, final and interim products and materials developed in whole or in part with AHRQ support, including, but not limited to, methodological tools, measures, software with documentation, literature searches, and analyses. Such copyrights and patents are subject to a royalty-free, non-exclusive, and irrevocable AHRQ license to reproduce, publish, use or disseminate for any purpose consistent with AHRQ’s statutory responsibilities and to authorize others to do so for any purpose consistent with AHRQ’s statutory responsibilities. In accordance with its legislative dissemination mandate, AHRQ purposes may include, subject to statutory confidentiality protections, making project materials, databases, results, and algorithms available for verification or replication by other researchers. In addition, subject to AHRQ budget constraints, final products may be made available to the health care community and the public by AHRQ or its agents if such distribution would significantly increase access to a product and thereby produce substantial or valuable public health benefits. Ordinarily, to accomplish distribution, AHRQ publicizes research findings but relies on grantees to publish research results in peer-reviewed journals and to market grant-supported products. AHRQ's Office of Communications and Knowledge Transfer (OCKT) wishes to be consulted in advance of publication in order to coordinate announcements of new AHRQ-supported research results with other AHRQ dissemination activities. Important legal rights and requirements applicable to AHRQ grantees are set out or referenced in AHRQ's grants regulation at 42 CFR Part 67, Subpart A (available in libraries and from the GPO's website at which incorporates additional applicable provisions on Rights in Data, including 45 CFR Part 74 and 37 CFR Part 401.

Post Submission Materials

Applicants are required to follow the instructions for post-submission materials, as described in NOT-OD-13-030.

Section V. Application Review Information

Important Update: See NOT-OD-16-006 and NOT-OD-16-011 for updated review language for applications for due dates on or after January 25, 2016.

1. Criteria

The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. As part of this mission, applications submitted to AHRQ to support health services research are evaluated for scientific and technical merit through the AHRQ peer review system.

Applications that are complete and responsive to the FOA will be evaluated for scientific and technical merit by an appropriate peer review group convened in accordance with standard AHRQ peer review procedures that are described in 42 CFR Part 67, Subpart A. Incomplete and/or non-responsive applications or applications not following instructions given in this FOA will not be reviewed. Only the review criteria described below will be considered in the review process.

Administrative Criteria: Upon receipt, applications will be evaluated for completeness by the Center for Scientific Review, NIH, and for responsiveness by AHRQ.

Merit Review Criteria: Merit Review Criteria, as described below, will be considered in the review process.

Overall Impact

Reviewers will provide an overall impact score to reflect their assessment of the likelihood for the project to exert a sustained, powerful influence on the research field(s) involved, in consideration of the following review criteria and additional review criteria (as applicable for the project proposed).

Scored Review Criteria

Reviewers will consider each of the review criteria below in the determination of scientific merit, and give a separate score for each. An application does not need to be strong in all categories to be judged likely to have major scientific impact. For example, a project that by its nature is not innovative may be essential to advance a field.


Does the project address an important problem or a critical barrier to progress in the field? If the aims of the project are achieved, how will scientific knowledge, technical capability, and/or clinical practice be improved? What will be the effect of these studies on the concepts, methods, technologies, treatments, services, or preventative interventions that drive this field?


Are the PD/PI, collaborators, and other researchers appropriately trained and well suited to carry out this work? Is the work proposed appropriate to the experience level of the PD/PI and other researchers? Do the PD/PI and investigative team bring complementary and integrated expertise to the project (if applicable)? Is the leadership approach, governance and organizational structure appropriate for the project? Is the applicant organization or a partner from a health care provider organization?


Is the project original and innovative? For example: Does the project challenge current research or seek to shift clinical practice paradigms; address an innovative hypothesis or critical barrier to progress in the field? Does the project develop or employ novel concepts, approaches or methodologies, tools, or technologies for this area?


Are the conceptual or clinical framework, design, methods, and analyses adequately developed, well-integrated, well-reasoned, and appropriate to the aims of the project? Does the applicant acknowledge potential problem areas and consider alternative strategies? Are benchmarks for success presented? If the project is in the early stages of development, will the strategy establish feasibility and will particularly risky aspects be managed?


Do(es) the scientific environment(s) in which the work will be done contribute to the probability of success? Do the proposed studies benefit from unique features of the scientific environment(s), or subject populations, or employ useful collaborative arrangements? Is there evidence of institutional support?

Additional Review Criteria

As applicable for the project proposed, reviewers will evaluate the following additional items while determining scientific and technical merit, and in providing an overall impact score, but will not give separate scores for these items.

Protections for Human Subjects

For research that involves human subjects but does not involve one of the six categories of research that are exempt under 45 CFR Part 46, the committee will evaluate the justification for involvement of human subjects and the proposed protections from research risk relating to their participation according to the following five review criteria: 1) risk to subjects, 2) adequacy of protection against risks, 3) potential benefits to the subjects and others, 4) importance of the knowledge to be gained, and 5) data and safety monitoring for clinical trials.

For research that involves human subjects and meets the criteria for one or more of the six categories of research that are exempt under 45 CFR Part 46, the committee will evaluate: 1) the justification for the exemption, 2) human subjects involvement and characteristics, and 3) sources of materials. For additional information on review of the Human Subjects section, please refer to the Guidelines for the Review of Human Subjects.

Degree of Responsiveness

Reviewers will assess how well the application addresses the purpose and objectives of this FOA. How responsive is the application to the special eligibility criteria, including the project requirements, noted in the FOA? []

Inclusion of Priority Populations

Reviewers will assess the adequacy of plans to address the needs of both genders, racial and ethnic minorities (and subgroups). Reviewers will assess the adequacy of attention to AHRQ priority populations (see above discussion on Priority Populations in section IV.6 Other Submission Requirements ).

Budget and Period of Support

The committee will evaluate whether the proposed budget is reasonable and whether the requested period of support is appropriate in relation to the proposed research. The committee will evaluate whether there is an effective and efficient use of project resources, including whether the request for equipment, hardware, or software does not exceed a total of 15% in any given year of the project.

Privacy and Security Protections for Patients

Reviewers will assess the resources and processes to be used to address privacy and security issues in the development and implementation of the intervention.


For Resubmissions (formerly "revised/amended" applications), the committee will evaluate the application as now presented, taking into consideration the responses to comments from the previous scientific review group and changes made to the project.

Additional Review Considerations

Not Applicable

2. Review and Selection Process

Applications will be evaluated for scientific and technical merit by (an) appropriate Scientific Review Group in accordance with AHRQ review policy and procedures, using the stated review criteria. Assignment to a Scientific Review Group will be shown in the eRA Commons.

As part of the initial merit review, all applications will:

As part of the scientific peer review, all applications:

Applications will be assigned on the basis of established AHRQ referral guidelines to the appropriate AHRQ Office or Center. Applications will compete for available funds with all other recommended applications submitted in response to this FOA. The following will be considered in making funding decisions:

3. Anticipated Announcement and Award Dates

After the peer review of the application is completed, the PD/PI will be able to access his or her Summary Statement (written critique) via the eRA Commons.

Generally, applicants should anticipate eight months between the application submission date and the earliest possible start date.

Section VI. Award Administration Information

1. Award Notices

If the application is under consideration for funding, AHRQ will request "Just-In-Time" information from the applicant. Just-In-Time information generally consists of information on other support, any additional information necessary to address administrative and budgetary issues, and certification of IRB approval of the project's proposed use of human subjects. For details regarding IRB approval, applicants may refer to the "AHRQ Revised Policy for Institutional Review Board (IRB) Review of Human Subjects Protocols in Grant Applications" (

Once all administrative and programmatic issues have been resolved, a formal notification in the form of a Notice of Award (NoA) will be provided to the applicant organization for successful applications. The NoA signed by the AHRQ grants management officer is the authorizing document and will be sent via email to the grantee’s business official.

Awardees must comply with any funding restrictions described in Section IV.5. Funding Restrictions.

Selection of an application for award is not an authorization to begin performance. Any costs incurred before receipt of the NOA are at the recipient’s risk. These costs may be reimbursed only to the extent considered allowable pre-award costs. See also Section IV.5., Funding Restrictions.

Any application awarded in response to this FOA will be subject to the DUNS, SAM Registration, and Transparency Act requirements as noted on the AHRQ web site at

2. Administrative and National Policy Requirements

All AHRQ grant and cooperative agreement awards are subject to AHRQ’s grants regulations at 42 CFR Part 67, Subpart A, the HHS Grants Policy Statement (see, and the terms and conditions set forth in the Notice of Award.

As necessary, additional Terms and Conditions will be incorporated into the NoA.

3. Reporting

When multiple years are involved, grantees will be required to submit the Non-Competing Grant Progress Report (PHS 2590) annually.

The annual progress reports must include Sections 2.2.6 A through F as described in the general PHS form 2590 instructions. For details regarding progress report submission, refer to If instructions on the AHRQ website are different from the PHS form 2590 instructions, follow the instructions on the AHRQ website.

The Progress Report is to include descriptive and evaluative comments on both completed activities and plans for the remainder of that year, including any changes foreseen in the future. At a minimum, the reports will include descriptive comments on: progress to date measured against project aims; methodological changes implemented; key preliminary findings; significant problems and resolutions; inclusion of priority populations; and project related publications, presentations, and dissemination activities. AHRQ does not currently limit the length of the progress report to 2 pages. AHRQ will provide the due date for submitting annual progress reports. In addition to the annual progress report, recipients may be required to submit quarterly progress reports to AHRQ. Detailed instructions on reporting requirements will be provided with the grant award.

Expenditure data is to be reported on the Federal Financial Report (FFR; SF 425). AHRQ requires annual financial expenditure reports for ALL grant programs as described in the HHS Grants Policy Statement (see AHRQ implementation of the FFR retains a financial reporting period that coincides with the budget period of a particular project. However, the due date for annual FFRs will be 90 days after the end of the calendar quarter in which the budget period ends. Note that this is a change in due dates of annual FFRs and may provide up to 60 additional days to report, depending upon when the budget period end date falls within a calendar quarter. For example, if the budget period ends 4/30/2013, the annual FFR is due 9/30/2013 (90 days after the end of the calendar quarter of 6/30/2013).

A final Progress Report, final Federal Financial Report, and Final Invention Statement are required when an award ends. All final reports are due within 90 days of the project period end date. For further details regarding grant closeout requirements, refer to

Section VII. Agency Contacts

We encourage inquiries concerning this funding opportunity and welcome the opportunity to answer questions from potential applicants.

Application Submission Contacts

eRA Service Desk (Questions regarding ASSIST, eRA Commons registration, submitting and tracking an application, documenting system problems that threaten submission by the due date, post submission issues)
Phone: 301-402-7469 or 866-504-9552 (Toll Free)

Web ticketing system:
TTY: 301-451-5939
Email: Customer Support (Questions regarding registration and submission, downloading forms and application packages)
Contact Center Phone: 800-518-4726

GrantsInfo (Questions regarding application instructions and process, finding NIH grant resources)
Telephone 301-710-0267
TTY: 301-451-5936

Scientific/Research Contact(s)

Direct your questions about general FOA issues, including information on the inclusion of priority populations to:

Kerm Henriksen, Ph.D.
Agency for Healthcare Research and Quality
Center for Quality Improvement and Patient Safety
Telephone: (301) 427-1331
Fax: (301) 427-1341
Email address:

Peer Review Contact(s)

Direct your questions about peer review issues of grant application made in response to this FOA to:

Andrew Louden, Ph.D
Agency for Healthcare Research and Quality
Office of Extramural Research, Education and Priority Populations
Division of Scientific Review
Telephone: (301) 427-1183
Fax: (301) 427-1561
Email address:

Financial/Grants Management Contact(s)

Direct your questions regarding fiscal matters to:

Steven Young
Office of Management Services
Grants Management
Agency for Healthcare Research and Quality
Telephone: (301) 427-1458
Fax: (301) 427-1462
Email address:

Section VIII. Other Information

Recently issued AHRQ policy notices may affect your application submission. A full list of policy notices published by AHRQ is provided in the NIH Guide for Grants and Contracts. Notices can also be found at AHRQ Grants Policy Notices. All awards are subject to the terms and conditions, cost principles, and other considerations described in the HHS Grants Policy Statement.

Authority and Regulations

This program is described in the Catalog of Federal Domestic Assistance at and is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review. Awards are made under the authority of 42 USC 299 et seq. and, 42 CFR Part 67 and in accordance with 45 CFR Parts 74 or 92 and other referenced applicable statutes and regulations. All awards are subject to the terms and conditions, cost principles, and other considerations described in the HHS Grants Policy Statement. The HHS Grants Policy Statement can be found at

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