Appendix B: Summaries of PFQ Grantee Activities

Important Note: Content for grant summaries was drawn from a variety of sources, including: 1) grantee proposals, progress reports, and other grant-related documents; 2) information obtained in interviews with grant principal investigators and project partners, 3) updates on progress, outcomes, findings, and products provided by grant project leaders. Where grantee-produced documents clearly stated goals, activities, or outcomes, we used that text for the summaries.  All grantee PIs or their staff had an opportunity to review the drafts of these summaries, and modify the text to ensure that it described their projects accurately.

Contents

Altarum Institute
American Academy of Pediatrics
American College of Physicians
American Hospital Association (AHA), Health Research and Educational Trust
American Medical Association
American Medical Directors Association Foundation
Association of California Nurse Leaders and California Nursing Outcomes Coalition
Catholic Healthcare Partners
Child Health Corporation of America
Connecticut Department of Public Health (DPH)
HealthFront
International Severity Information Systems, Inc.
Joint Commission on Accreditation of Healthcare Organizations
The Leapfrog Group
Lehigh Valley Hospital and Health Network
New York State Department of Health
Physician Micro Systems, Inc.
Research Triangle Institute
Texas A&M University System
Visiting Nurse Service of New York

PFQ Grant Summary: Improving Health Care Responses to Bioterrorist Events

Lead Organization: Altarum Institute
Partner Team: Altarum Institute, Michigan Center for Biological Information (MCBI), University of Michigan Department of Emergency Medicine; Texas Community Emergency Health Care Initiative (CEHI), University of Texas Health Science Center, Texas A&M University, US Army Medical Department Board, National Pharmaceutical Stockpile of the Centers for Disease Control and Prevention, various organizations within the two target communities.
Title: Improving Health Care Responses to Bioterrorist Events
Topic Area: Bioterrorism and emergency preparedness
Principal Investigators: George Miller, PhD
AHRQ Project Officer: Sally Phillips
Total Cumulative Award: $397,835
Funding Period: 9/2002–9/2006
Project Status: Completed 9/29/2006

1. Project Description

Goals. The project planned to employ the Healthcare Complex Model (HCM), a simulation modeling tool, to plan for the care that victims would need from the acute medical delivery system following a bioterrorist attack. The project proposed testing the utility and validity of HCM in supporting bioterrorism readiness planning in both a rural and an urban health care network by estimating the demand for care by medical facilities.  

Project goals expanded to include the development of another model, the casualty prediction model (CPM), which, using alternative assumptions about the public health response, would estimate the spread of disease following an attack. Both models were intended to assist community efforts to plan for medical care and public health responses, including such issues as staffing, supplies, and patient flow, in the event of bioterrorism attacks or other emergency, such as naturally occurring influenza outbreaks.  

Activities and Progress 

Year 1. Work on the grant did not begin until March 2003, halfway through the first project year, because of delays in AHRQ's release of funds to PFQ grantees. The project convened a series of meetings with partners to discuss HCM's capabilities and solicit their input on setting up and analyzing the rural scenario in which to deploy HCM.  The project decided to model pneumonic plague for the first application and chose Smithville Hospital, a rural hospital in Bastrop County, Texas, as the setting. The project obtained and prepared population, clinical, and facility data (input data) for the rural scenario through its partnership with the Texas CEHI and with the cooperation of the Smithville Hospital staff.  

The project used the data to create several model cases that investigated alternative response strategies for dealing with a plague outbreak. Such responses included augmenting the existing medical infrastructure with volunteers and state and federal assets, for example.  The analysis of the first application of HCM activity showed that, even in a rural setting with a very small number of initially infected victims, early detection of an attack and subsequent aggressive response could result both in saving a significant number of lives and in significantly reducing the demand for scarce resources needed to treat primary and secondary victims.  The model and data that were developed for the rural setting in phase 1 could be easily extended to address issues of interest to planners in a specific community or to further general planning for rural hospital preparedness.  

The HCM benefited from enhancements made in response to its use in the rural scenario.  In particular, the project developed the CPM to serve as an input to the HCM and generate a patient/casualty stream that would impose demands on the acute care system in the model. Enhancements to HCM, including the addition of the CPM, were carried over to the second application of HCM in an urban setting in the second project year. 

Year 2. For the second application of HCM, the project chose the San Antonio, Texas, area as the urban setting in which to simulate a terrorist-produced smallpox outbreak. It developed various options for the public health system to use to reduce the number of victims and for the acute care system to use to improve patient outcomes. The CPM and HCM were used to study several scenarios designed to determine the effects of early and aggressive attempts to immunize the population (mass vaccination) versus more deliberate and time-consuming tracing and immunization (ring vaccination).  The project sought to closely integrate the functions of the CPM with those of the HCM so that they could improve their representation of the interrelationship between public health activities and the provision of acute care.

The project presented to public health and hospital officials in the San Antonio area what had been learned from the CPM model about the impacts of varying public health responses to a smallpox attack (including alternative vaccination programs, various actions to reduce the frequency of contacts between infective and susceptible individuals, and isolation of infective victims) on the magnitude of the patient stream arriving for treatment at medical facilities.  One finding suggested that a policy of mass vaccination results in many fewer victims and a lower chance of an epidemic than does tracing and immunization alone.  The HCM modeled the daily number of victims presenting for medical care, cumulative mortality, and demand for health care resources (e.g., demand for ICU beds) after a smallpox outbreak, given varying public health response measures. The model found that daily victims, mortality, and demand for healthcare resources tended to be lowest with the use of a mixture of public health measures rather than extensive use of a single measure. However, unless the attack was very small, these measures were unlikely to prevent a surge in demand for acute care that would require community-wide coordination of resources, a definitive patient triage policy, and temporary treatment practices.

Year 3. Activities in the third project year included a quantitative investigation of the benefits of improved surveillance on the ability to react to a smallpox attack; an analysis of the use of quarantine in response to a smallpox attack; and a validation study of the CPM.   Early on, the project had established a partnership with Texas A&M, another PFQ grantee that was also doing bioterror work, and that partnership helped in gathering the input data for the study. The results  suggested that early detection and response reduced the number of eventual victims, as mass vaccination reaches a larger percentage of the population before exposure.  They also confirmed that initiating smallpox vaccination less than six days after the event had essentially no additional benefit, but that pursuing detection and response early enough to benefit the second generation of possible infections was necessary. In addition, the model found that a voluntary quarantine program as an adjunct to a ring vaccination program might dramatically decrease the total number of smallpox victims.  The project also validated the CPM by configuring it to represent influenza and then showing it capable of producing values that are consistent with empirical data collected during epidemiology studies of populations experiencing an influenza outbreak.

Year 4. Since the project had already configured the CPM to represent influenza for the validation study, the project decided to modify the CPM to allow investigation of the impact of targeted vaccinations of public health workers and other first responders in the event of an influenza outbreak.  Texas A&M University again assisted the project by providing input data.  Results from the analysis showed the importance of establishing a sufficient level of immunity in the first responder and health care worker subpopulations because of their high risk of contact with infective victims.  Immunity in these subpopulations is important since the analysis showed that infection among them will adversely affect the ability of the community to respond to the epidemic. The project also cast doubt on the argument to establish immunity within these subpopulations prior to the epidemic, principally since small numbers of first responders and health care workers are involved.  An ongoing effort involves investigating the effectiveness of other specific strategies to combat an influenza epidemic in San Antonio.

2. Partnership Structure/Function

Many of the people and organizations listed as partners in the project were consultants or advisors, lending their subject expertise in the development of the models (see table below).  Communication between Altarum and these experts occurred as needed, increasing in frequency when models were being refined.  Other partners listed, including CEHI, Texas A&M, and some of the target organizations, were actively involved in obtaining the data necessary to run the various simulations. Communication between Altarum and the two communities that served as the simulation settings—San Antonio and rural Bastrop County near Austin—were not regularly scheduled, but communication did increase while project was gathering information.  The project also scheduled seminars and briefings in the San Antonio area to keep the community abreast of the project's work. 

Table 1. Major Partner Organizations and Roles in the Project

	Organization	Role in Project
Lead Organization (grant recipient)	The Altarum Institute	Led the project, providing knowledge and expertise based on the company's history working with advanced informatics systems solutions and knowledge tools
Key Collaborators	Texas Community Emergency	Helped to identify the setting and obtain input Healthcare Initiative (CEHI) data for the rural scenario to be used in HCM Served as a functional expert in reviewing model output
	Texas A&M University	Provided input data for the influenza model and the representation of surveillance in the third and fourth project years
	Consultants: Michigan Center for Biological Information (MCBI) University of Michigan Medical Center Department of Emergency Medicine University of Texas (UT) Health Science Center U.S. Army Medical Department Board Centers for Disease Control and Prevention, National Pharmaceutical Stockpile	MCBI served as functional expert on bioinformatics, biological warfare, and terrorism University of Michigan served as functional experts in selecting the diseases to be investigated, identifying needed data, reviewing results for validity, and inferring useful observations UT provided subject matter expertise to help develop the models and validate the models' assumptions; also provided public health contacts in the community The Army Medical Department Board reviewed results and assisted with other contacts within the Department of Defense medical community Representatives of the National Pharmaceutical Stockpile provided a critique of the HCM
Target Organizations	Two Communities: San Antonio—including representatives of Region 8 of the Texas Dept. of State Health Services, San Antonio Metropolitan Health District, Greater San Antonio Hospital Council, Southwest Texas Regional Advisory Council, Brooke Army Medical Center, and Wilford Hall Medical Center Smithville Hospital in Bastrop County, TX (near Austin)	Provided settings and assisted in identifying associated data and assumptions for model simulations

3. Project Evaluation and Outcomes/Results

Altarum had been working with the HCM model prior to the AHRQ grant, using it for simulations in other contexts, including flow of patients in health systems, facilities planning, staffing, and telemedicine. The PFQ grant provided Altarum with an opportunity to continue this work and to test its utility for other simulation exercises.  

The project successfully used its two models to provide information for bioterrorism planning in public health and in health care systems at the community level.  One piece of information provided to the public health system in San Antonio was especially useful—that vaccinating 40,000 people a day (rather than the 270,000 the system had intended) in the event of a smallpox outbreak would be enough to control the epidemic.  According to one respondent, this information helped the public health authority in San Antonio determine the number of vaccine distribution sites needed, and the correct number of sites is now in its plans.  Other information provided by the smallpox simulation changed the public health authority's purchasing strategy for bioterror preparedness supplies. The authority decided to prioritize buying certain supplies (e.g., ventilators, isolations rooms, etc.) in hospitals and coordinated and standardized the equipment purchased at those hospitals.  Beyond these two examples, it is unclear how much the communities that served as the locations for the simulations used the information from the study to make other practice or policy changes.  However, the models and data that were developed for both the rural and urban settings can be extended to address issues of interest to planners in a specific community or to further planning for hospital and public health system preparedness.  The project also validated the use of CPM for other disease outbreaks.

4. Major Products

• Miller, G., S. Randolph, and D. Gower. "Simulating the Response of a Rural Acute Health-Care Delivery System to a Bioterrorist Attack." International Journal of Disaster Medicine, vol. 2, 2004, pp. 24-32.
• Miller, G., S. Randolph, and J.E. Patterson. "Responding to Bioterrorist Smallpox in San Antonio."  To appear in Interfaces, November-December 2006.
• Testimony at a Joint Meeting of the Senate Judiciary and House Veterans Affairs/Homeland Security Committees of the Michigan Legislature, October 2003.
• Presentations to the University of Texas Health Science Center, December 2003 and January 2005.
• Seminar at Case Western Reserve University, March 2004.
• Presentations at national meetings of the Institute for Operations Research and the Management Sciences, October 2004 and November 2005.
• "Modeling Public Health and Medical Treatment Responses to Smallpox and Influenza Outbreaks." Paper presented at the San Antonio and Austin Life Sciences Association Biodefense Summit, April 21, 2006.
• "Responding to Bioterrorist Smallpox in San Antonio." Paper presented as part of the Colloquium Series of the Management Science and Statistics Department, College of Business, University of Texas at San Antonio, April 25, 2006.
• Presentation at the U.S. Army Force Health Protection Conference, August 2006.

5. Potential for Sustainability/Expansion after PFQ Grant Ends

After the grant ends, Altarum will continue working with both the HCM and CPM.  The principal investigator hopes eventually to use the models to study a health system network representation of the spread of disease. The project's most recent work under the grant on targeted vaccinations is a step in this direction. Though the San Antonio community expressed interest, it has not committed any funds to continue the modeling work. Altarum believes that the U.S. Department of Defense (DoD), which has more resources to devote to planning for community disaster assistance, is a more likely source of funding for follow-up work, and it has initiated discussions with DoD agencies.  

Return to Appendix B Contents

PFQ Grant Summary: Partnership to Improve Children's Health Care Quality

Lead Organization: American Academy of Pediatrics (AAP)/ Center for Health Care Quality at Cincinnati Children's Hospital Medical Center (CCHMC) [Note: Grant shifted from the National Initiative for Children's Healthcare Quality (NICHQ) to AAP in June 2004.]
Partner Team: AAP and CCHMC with an advisory board comprising American Board of Pediatrics (ABP), Children and Adults with Attention Deficit Disorder (CHADD), etc.; also 10 AAP state chapters and 186 local pediatric practices.
Title: Partnership to Improve Children's Health Care Quality
Topic Area: Improve care for children with attention deficit hyperactivity disorder (ADHD)
Principal Investigators: Dr. Carole Lannon, MD, MPH, Center for Health Care Quality, CCHMC
AHRQ Project Officer: Charlotte Mullican
Total Cumulative Award: $1,298,266
Funding Period: 9/2002–9/2006
Project Status: Completed 9/29/2006

1. Project Description

Goals. This project sought to improve care for children with ADHD by teaching physicians to use an interactive web-based Continuing Medical Education (CME) quality improvement tool called Education in Quality Improvement for Pediatric Practice (eQIPP).  It did so drawing on the combined resources of a partnership among the CCHMC, AAP, ABP, and an advisory board of experts and related organizations, as well as state AAP chapters and pediatric practices. The project was designed to 1) improve pediatricians' adherence to evidence-based care guidelines for children with ADHD through a training program that taught physicians to measure their processes of care with an on-line tool; and 2) develop the capacity of local chapters of professional medical organizations to support members' improvement activities. AAP also wanted to gain recognition of this measurement-based CME program as qualifying for new ABP "maintenance of certification" requirements. If successful, the model would be used to address other health issues of children.  Finally, the participating organizations hoped to learn more about the use of professional organizations to facilitate improvement at the practice level.

Activities and Progress. Year 1 of the project was spent on planning and development activities. Project staff established an advisory board, recruited and selected AAP chapters to participate in the first year of the intervention, finalized an evaluation plan and measures of success, and developed recruitment and training materials for AAP chapters and practices. 

Prior to receiving the PFQ grant, the AAP developed an ADHD eQIPP module.  An interactive tool for pediatricians that is available on-line eQIPP incorporates specific content education and teaches QI principles as applied to the content area.  For this project, eQIPP helps physicians to assess their practices by having them answer 5-10 questions based on a review of at least 10 patient charts, and then provides feedback that allows them to evaluate their performance against relevant comparison measures and benchmarks.  Physicians using eQIPP get CME credit and opportunities to track progress and monitor changes in practice over time.  

In year 2, the project team (AAP/CCHMC) began technical assistance and ongoing support to the four selected AAP chapters. (Initially, the project team selected five AAP chapters but one chapter deferred participation until the following year.)  Each selected chapter was given $13,000 to use for additional staff, program costs, or other infrastructure needs.  AAP chapters were responsible for recruiting pediatric practices to participate in this project.  Once the practices agreed to participate, the AAP chapters helped them to enroll in eQIPP and work through the ADHD module to complete a "prework" assignment prior to a six-hour training workshop held by their AAP chapter.  The participating practices used eQIPP to collect baseline performance measurements on their care for children with ADHD.

At the training workshop, the participants learned to 1) apply key change concepts in caring for children with ADHD; 2) identify essential components of a staged implementation plan for providing optimal care for this chronic condition; 3) plan strategies for difficult cases; 4) develop partnerships with parents, educators, and behavioral health providers and community groups; and 5) provide education and support for parents and families.  The AAP/CCHMC project team provided guidance for each chapter's workshop preparation and led the quality improvement and measurement sessions at each workshop.  

In year 3, the project team recruited an additional five AAP chapters and began the same series of training work with them (as well as with the chapter from year 2 that deferred participation).  The project team also continued technical assistance to the original four AAP chapters and participating practices.  In August 2005, the project held a one-day conference for AAP chapter presidents, just prior to the AAP Annual Leadership Forum, to highlight and share what chapters had learned about initiating local improvement efforts and supporting practices to improve care.

In year 4, the project team focused on completing the ADHD improvement efforts with the 10 AAP chapters.  The team also refined its plans for evaluation and completed data collection efforts.  In August 2006, the project team held a chapter leader workshop, bringing together 18 chapter teams, composed of AAP chapter leadership (executive director and physician champion) as well as local public health agency partners (such as state maternal and child health departments or Medicaid directors), in order to share lessons on how to build interest in QI, integrate QI into CME programs, and support the QI change process in practices.  Public health agencies were invited because project directors believe that chapters were most successful in sustaining activities following the initial workshop when they partnered with such organizations.  

2. Partnership Structure/Function

The principal investigator (PI) is located at CCHMC, although the grantee is the AAP.¹ The two organizations jointly comprise the core project team and together manage the project.  They hold monthly conference calls and have worked as partners to coach the AAP chapters to recruit practice teams, prepare practice teams for the improvement workshops, plan and conduct the workshops, manage eQIPP enrollment and data collection, and support the development of the chapters' improvement infrastructure.  

The CCHMC-AAP project team was divided into three subgroups: 1) improvement partnerships, to develop an ongoing improvement infrastructure and support AAP chapters in sustaining improvement work after the PFQ project, 2) curriculum development, to assess the ADHD workshop curriculum and review the ADHD toolkit and eQIPP modules, and 3) evaluation, to develop the measurement strategy, data collection tools, and workshop evaluations as well as to collect and compile monthly data from the chapters and eQIPP data from the practices.  Monthly conference calls are held between the advisory board and project team subgroups.

Monthly conference calls are also held between the CCHMC-AAP project team and the AAP chapters. These calls serve to coach chapter leaders in the recruitment of practices, help pediatricians with preworkshop preparation, plan the workshops, and coordinate with expert faculty.

Regular calls take place between the CCHMC-AAP project team, the AAP chapters, and the participating practices.  For example, the CCHMC-AAP project team held calls in early 2006 to discuss topics of interest to the practices, such as CHAAD parent-to-parent training and mimickers of ADHD.  In addition, the project team, chapters, and practices communicate with each other via the project's electronic listserv. Weekly, the CCHMC-AAP project team send a case study to the listserv and practices respond, ask questions, and/or share their experiences.

Table 1. Major Partner Organizations and Roles in the Project

	Organization	Role in Project
Lead Organization (grant recipient)	American Academy of Pediatrics (AAP)/Center for Health Care Quality, Cincinnati Children's Hospital Medical Center (CCHMC) [Note: Original grant recipient was the National Initiative for Children's Healthcare Quality (NICHQ), but this shifted to AAP in 2004. The PI is based at CCHMC.]	Provides overall leadership; coordinates communication between partner sites, and manages the project timeline Coaches the AAP chapters to recruit practice teams, prepares practice teams for the improvement workshops, plans/conducts the workshops, manages eQIPP enrollment and data collection, and supports the development of the chapters' improvement infrastructure
Key Collaborators	Advisory board [Members include: AAP, American Board of Pediatrics (ABP), Children and Adults with Attention Deficit Disorder (CHADD), and the American Board of Medical Specialties (ABMS)]	Provides counsel regarding challenges with implementation and facilitating communication, of project activities through various partnership channels
Target Organizations	10 AAP state chapters (yr. 2: IN, MS, NM, VA; yr. 3: CT [deferred from yr. 2], FL, MD, OK, UT, WV) 186 pediatric care practices in the 10 states with participating AAP chapters	Recruit primary care practices to participate in project; organize and sponsor training workshops; offer technical assistance and training to practices Attend workshop, implement practice changes, and collect/report data using eQIPP

3. Project Evaluation and Outcomes/Results

The evaluation will address three major research questions:  1) Does the frequency and participation in improvement activities differ between practices enrolled in eQIPP alone and those enrolled in eQIPP with an AAP chapter support program?  2) Will appropriate disease management for ADHD improve across time for the treatment group? 3) What factors contribute to or inhibit a chapter's ability to improve and to sustain improvement?

The evaluation will not assess the impact of the program on patient outcomes because the link between the improved process of care delivery to children and better outcomes for children with ADHD has already been established.  

As of March 31, 2006, 115 individuals had entered 1304 chart reviews (612 from year 2 and 692 from year 3) into unit 1 of the eQIPP program as part of the prework for the AAP chapter workshop. Final aggregate reports are being prepared. These reports will show the proportion of charts demonstrating the target level of care for the seven components of diagnosis and treatment for ADHD by all participating practices and by participating practices in each chapter. A manuscript describing the findings based on this data is in progress (listed under publications).

As of March 31, 2006, 45 individuals had entered follow-up data from 498 chart reviews (299 from year 2 and 199 from year 3) into unit 4 of the eQIPP program. Final aggregate reports showing follow-up data will be provided to the chapter teams that reached the 50-chart minimum instituted by the AAP.

Interviews have been conducted with team members from all 10 participating chapters. The interview data will be used in the overall evaluation to measure progress toward project aims and will also help the AAP in planning future chapter supports for quality improvement efforts. A manuscript describing the results of the interviews is in progress (listed under publications).  Interviews of AAP leaders will also be conducted in the final year of the program.

All participating physicians were surveyed about their experiences with the project and the eQIPP program. The survey was initially distributed electronically and then followed up with two mailings. Analysis of responses is under way.

4. Major Products

• Resource toolkit (more than 75 pages), based on evaluation results for AAP chapter leaders, containing guidance on getting started and making presentations, as well as information on basic QI methods, successful improvement activities from AAP chapters, and workshop materials (currently in development). Two copies of each toolkit will be provided to each chapter.  In addition, the guide will be available on the AAP's Web site and updated regularly.
• Team members led a workshop, "From National to Local Improvement:  A Multi-Faceted Intervention to Improve Care for Children with ADHD" at the NICHQ 5^th Annual Forum for Improving Children's Healthcare in Orlando, FL, in March 2006.
• Two posters were presented at the Pediatric Academic Societies Annual Meeting in San Francisco, CA, in April, 2006: "Partnership for Quality: Structured Support to Improve Care for Children with ADHD" and "Measuring Performance in Practice for the Care of Children with ADHD."
• An article entitled "Chapter-Based Collaborations Improving Care for Children" will be published in the AAP News in June 2005.
• At least four manuscripts are anticipated:
  • Lazorick, Suzanne, Virginia L.H. Crowe, Judith C. Dolins, and Carole M. Lannon. "All Improvement is Local: Evaluating the Use of an Innovative, Multi-Faceted Intervention by a National Professional Organization to Translate its Guidelines into Practice."  Based on poster sessions at the Academy Health Annual Research Meeting and Child Health interest group, Boston, MA, June 27, 2005 and the NRSA Fellows meeting, Boston, MA, June 28, 2005; and a presentation at the AHRQ Translating Research Into Practice meeting, Washington DC, July 17, 2005.
  • Lannon, Carole M., Suzanne Lazorick, Judith Dolins, and Thaddeus Anderson. "Measuring Performance in Practice for the Care of Children with ADHD."
  • Lannon, Carole, Judy Dolins, Suzanne Lazorick, and Virginia L.H. Crowe. (manuscript in preparation for journal supplement, Joint Commission Journal on Quality and Safety, spring 2007).
• Manuscript on practice changes in disease management as a result of participation in PFQ.
• Dr. Lannon discussed the PFQ project at three workshops at the AAP SuperCME meeting in Orlando, FL, April 29-30, 2004.  In addition, Dr. Lannon outlined how the PFQ project can help residency-training programs meet the requirements of the ACGME competencies at the Association of Pediatric Program Directors meeting and at the Continuity Clinic Special Interest Group at the Ambulatory Pediatric Association.
• Dr. Lannon used multiple examples from PFQ in presentations to the AAP Annual Leadership Forum in August 2004 and the AAP Board of Directors, October 2004.
• At the AAP National Conference and Exhibition, November 1-5, 2003, Dr. Lannon presented a workshop: "Think Globally, Act Locally: Working with Chapters to Improve Quality of Care."

5. Potential for Sustainability/Expansion after PFQ Grant Ends

It is likely that this program will continue after the end of the grant.  AAP has hired a full-time staff person whose responsibility is to continue working with the state chapters on quality improvement initiatives. Plans are under way to develop additional eQIPP modules.  At the August 2006 meeting, planning for an ongoing learning network for chapters was begun.  

Also, the AAP chapters participating in PFQ have continued and expanded work begun in the PFQ project.  Three of these chapters are continuing with the ADHD project and four have formed new partnerships to improve care for children with ADHD.  Six chapters have gone on to design or implement other quality improvement projects. Three of these have secured additional funding and five have developed new partnerships to conduct quality improvement projects.  As a result of participation in the PFQ project, six chapters have made other specific changes to promote a quality improvement focus. For example, the New Mexico AAP chapter received other grant funds to develop a quality improvement program focusing on obesity prevention, in partnership with the University of New Mexico's Department of Pediatrics and the New Mexico Human Services Department. 

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^1. The PFQ grant was originally awarded to the National Initiative for Children's Healthcare Quality (NICHQ), but shifted to the American Academy of Pediatrics in 2004, when the PI's center left that organization. The PI is currently located at CCHMC.  

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