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) 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) 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) 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: 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 (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 301/710-0267, Email: 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, (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: 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: 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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