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AHRQ's Role in Improving Quality, Safety, and Health System Performance

Richard kronick , phd.

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Address correspondence to: Richard Kronick, PhD, U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, 5600 Fishers Ln., 7th Fl., Rockville, MD 20857, Phone: 301-427-1100, Email: [email protected] .

Corresponding author.

The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency charged with improving the quality and safety of America's health-care system. AHRQ develops the knowledge, tools, and data needed to improve health system performance and help patients, health-care professionals, and policy makers make informed health decisions. The research, tools and training, and data and measures that AHRQ produces enable close collaboration with U.S. Department of Health and Human Services (HHS) agencies and other partners to ensure that the evidence produced is understood and used to achieve the goals of better care, smarter spending of health-care dollars, and healthier people.

The 2010 Patient Protection and Affordable Care Act has made great strides in transforming American health care, with an estimated 17.6 million additional Americans receiving health-care coverage 1 compared with 49.9 million uninsured in 2010. 2 Although expansion of the Affordable Care Act's coverage has garnered the most attention, the law's quality and safety provisions may have even more impact on U.S. health system performance in the long term. The latest evidence is shown in an HHS report released in December 2015 on hospital-acquired conditions (HACs). 3

According to the report, from 2010 to 2014, hospital patients had an estimated 2.1 million fewer HACs than they would have had if rates of adverse events had remained at the 2010 level of 145 HACs per 1,000 hospital discharges. Fewer HACs resulted in 87,000 fewer patients dying in hospitals and a reduction of nearly $20 billion in health-care costs. 3 These findings build on results reported in December 2014, which showed that 50,000 fewer patients died in hospitals and $12 billion in health-care costs were saved from 2010 to 2013. 4 Overall, from 2010 to 2014, the number of adverse events declined by 17%, dropping from 145 adverse events per 1,000 hospital discharges to 121 adverse events per 1,000 hospital discharges. 3

Improving patient safety requires efforts from many actors. Clinicians and staff members in hospitals across the United States were fundamental to this progress. The Affordable Care Act also played a key role in these efforts through the HHS Partnership for Patients initiative, a public-private collaboration of health-care providers, employers, patients, and federal and state governments. The initiative, launched in 2011, focused on improving health-care safety by lowering the rate of HACs and decreasing preventable complications that can result in hospital readmissions. 5 Progress was further incentivized by changes in Medicare payment, which galvanized the attention of hospital leaders. For example, under the Affordable Care Act, Medicare reduced payments to the 25% of hospitals whose rate of HACs fell within the highest quartile. 6 Translating HHS's policy aims of better care, smarter spending, and healthier people into practice requires strong, diverse public-private partnerships, including frontline clinicians, institutions, and patients and families. In addition to the Partnership for Patients initiative, these efforts include hospital engagement networks, quality improvement organizations, and many other public and private partners.

TOOLS, RESOURCES, AND DATA

Tools, resources, and data from AHRQ are essential to these efforts. The tools, knowledge, and data that AHRQ develops and funds are foundational to creating a health-care system that is safe, timely, effective, efficient, equitable, and patient-centered. 7 AHRQ contributes to creating a higher-performing health system in three major ways.

Investing in research and evidence to understand how to improve the safety and quality of health care

AHRQ supports research to improve U.S. health system performance. AHRQ generated much of the basic evidence about how to improve the safety of hospital care, starting with evidence on how to reduce central line-associated bloodstream infections. 8 Central line-associated bloodstream infections can occur when bacteria or other germs enter a central line or catheter placed in a patient's large vein to facilitate medical treatment. These infections can lead to death and add billions of dollars in health-care costs each year. Until the mid-2000s, it was generally accepted by physicians that central line infections were a cost of doing business in the intensive care unit (ICU). Some ICU patients needed central lines, and some of those central lines would become infected, leading to bloodstream infections that contributed to longer hospital stays and high mortality rates. AHRQ-funded research demonstrated that central line infections could be prevented, and data from a 2015 report on HACs showed a 72% reduction in central line infections nationwide from 2010 to 2014. The 2010 baseline measure for central line infections was 18,000; by 2014, it had decreased to 5,000, fueled by national education and outreach through Partnership for Patients and with tools and resources, many of which were based on AHRQ-funded research. 9

Other AHRQ-funded projects include our Evidence-based Practice Centers, 13 academic and research organizations that review scientific literature on a wide spectrum of clinical and health services topics 10 and provide evidence for the U.S. Preventive Services Task Force. AHRQ also supports investigator-initiated research. One example of this AHRQ-funded research is an innovative model for training and supporting primary clinicians in rural communities in New Mexico to provide specialized care for their patients. 11

Creating materials to teach and train health-care professionals to catalyze system-wide improvements in care

AHRQ has credibility and an excellent ongoing relationship with the health-care provider community. Tools and resources such as the Surveys on Patient Safety Culture 12 and TeamSTEPPS ® training materials, an evidence-based teamwork system aimed at improving communication and teamwork skills among health-care professionals, 13 are widely used in hospitals, physician practices, and other settings of care. These materials vary widely in scope but together translate the latest evidence from bench to bedside.

One prominent example of AHRQ's work with providers is the development and implementation of the Comprehensive Unit-based Safety Program (CUSP). CUSP is a customizable program that combines clinical best practices with the science of safety, improved safety culture, and an increased focus on teamwork. Developed by Johns Hopkins researchers with AHRQ funding, it has been a major force in reducing central line infections. 14 CUSP was later applied to catheter-associated urinary tract infections, reducing such infections in more than 950 hospitals by about 15% from 2011 to 2015. 15 The CUSP Toolkit brings together practical resources based on the experiences of thousands of hospitals that have used CUSP with learning materials that help providers understand key principles that increase safety. Add-on modules target safety issues and settings of care. 16

Generating measures and data used to track and improve performance and evaluate progress of the U.S. health-care system

AHRQ's data products are the national gold standard in providing information to providers, patients, and policy makers to track progress, identify problem areas, and catalyze quality improvement. The Healthcare Cost and Utilization Project, a family of databases containing information extracted from administrative data, is the largest and most robust database available on the care provided to hospital patients in the United States. 17 The Medical Expenditure Panel Survey, which is a set of large-scale surveys of families and individuals, their providers, and employers in the United States, is the most complete source of data on the cost and use of health care and insurance. 18 The Consumer Assessment of Healthcare Providers and Systems surveys ask consumers to evaluate their experiences with health care. Survey topics focus on aspects of quality that consumers are best qualified to assess, such as the providers' communication skills and ease of access to health-care services. 19

These data resources and national surveys, along with products such as the annual National Healthcare Quality and Disparities Report 20 and AHRQ's Quality Indicators, 21 comprise a robust set of data sources that researchers and policy makers can use to identify trends and potential interventions. For example, AHRQ data highlighted a 153% increase in adult hospitalizations for overuse of opioids between 1993 and 2012, increasing from 117 opioid-related hospitalizations per 100,000 population in 1993 to 296 opioid-related hospitalizations per 100,000 population in 2012. These data helped prompt HHS's launch of a 2015 initiative to reduce opioid use. 22

FUTURE STEPS

AHRQ continues to explore ways to expand its efforts in patient safety into nonhospital settings. Initial efforts to improve safety focused on the sickest and most vulnerable patients (i.e., those treated in hospital settings). However, health care is increasingly provided in nonhospital settings, such as outpatient surgery centers and physician offices, albeit to less vulnerable patients. Efforts such as the opioid use reduction initiative 22 and the New Mexico rural physician training and support program 11 demonstrate AHRQ's commitment to assessing and improving the performance of health care wherever patients receive it.

High-performance health care, which is the goal of the Affordable Care Act's quality and safety provisions, means getting the right care delivered to the right patient at the right time, using resources wisely, respecting patients' and families' preferences, and reducing errors. The Affordable Care Act enables structural changes to the health-care system that reward these aims. The law is already keeping patients safer in hospitals, as evidenced by reductions in adverse events and thousands of lives saved. And that's just the beginning. AHRQ is building a health system informed by evidence, much of which is being generated by AHRQ. Researchers and scientists look forward to working within HHS and with other partners and stakeholders to fulfill the vision of a safer, high-quality health-care system that serves all people equally and efficiently.

• 1. Department of Health and Human Services (US), Office of the Assistant Secretary for Planning and Evaluation. Health insurance coverage and the Affordable Care Act. ASPE Data Point 2015 Sep 22 [cited 2016 Jan 15] Available from: https://aspe.hhs.gov/sites/default/files/pdf/111826/ACA%20health%20insurance%20coverage%20brief%2009212015.pdf .
• 2. Department of Health and Human Services (US), Office of the Assistant Secretary for Planning and Evaluation. ASPE Issue Brief: overview of the uninsured in the United States: a summary of the 2011 Current Population Survey. 2011 [cited 2016 Jan 28] Available from: https://aspe.hhs.gov/basic-report/overview-uninsured-united-states-summary-2011-current-population-survey .
• 3. Department of Health and Human Services (US), Agency for Healthcare Research and Quality. Rockville (MD): AHRQ; 2015. Dec, Saving lives and saving money: hospital-acquired conditions update: interim data from national efforts to make care safer, 2010–2014. Also available from: www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2014.html [cited 2016 Jan 15] [ Google Scholar ]
• 4. Department of Health and Human Services (US), Agency for Healthcare Research and Quality. Rockville (MD): AHRQ; 2014. Dec, Interim update on 2013 annual hospital-acquired condition rate and estimates of cost savings and deaths averted from 2010 to 2013. Also available from: http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2013.html [cited 2016 Jan 15] [ Google Scholar ]
• 5. Centers for Medicare & Medicaid Services (US) Partnership for Patients [cited 2016 Jan 18] Available from: https://partnershipforpatients.cms.gov .
• 6. Department of Health and Human Services (US), Centers for Medicare & Medicaid Services. Hospital-Acquired Condition (HAC) Reduction Program [cited 2016 Jan 28] Available from: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientPPS/HAC-reduction-program.html .
• 7. Department of Health and Human Services (US), Agency for Healthcare Research and Quality. The six domains of health care quality [cited 2016 Jan 18] Available from: https://cahps.ahrq.gov/consumer-reporting/talkingquality/create/sixdomains.html .
• 8. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU [published erratum appears in N Engl J Med 2007;356:2660] N Engl J Med. 2006;355:2725–32. doi: 10.1056/NEJMoa061115. [ DOI ] [ PubMed ] [ Google Scholar ]
• 9. Department of Health and Human Services (US), Agency for Healthcare Research and Quality. Saving lives and saving money: hospital-acquired conditions update. Exhibit A2. December 2015 [cited 2016 Jan 18] Available: from: www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhac2014-ap1.html .
• 10. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. Evidence-based Practice Centers (EPC) program overview [cited 2016 Jan 18] Available from: www.ahrq.gov/research/findings/evidence-based-reports/overview/index.html .
• 11. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. Project ECHO: Extension for Community Healthcare Outcomes (New Mexico) [cited 2016 Jan 18] Available from: https://healthit.ahrq.gov/ahrq-funded-projects/project-echo-extension-community-healthcare-outcomes .
• 12. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. Surveys on patient safety culture [cited 2016 Jan 19] Available from: www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html .
• 13. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. TeamSTEPPS®: Strategies and Tools to Enhance Performance and Patient Safety [cited 2016 Jan 19] Available from: www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html .
• 14. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. AHRQ patient safety project reduces bloodstream infections by 40 percent [press release] 2012 Sep 10 [cited 2016 Jan 19] Available from: www.ahrq.gov/news/newsroom/press-releases/2012/20120910.html .
• 15. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. AHRQ patient safety toolkit helps hospitals reduce catheter-associated urinary tract infections (CAUTI) [press release] 2015 Nov 19 [cited 2016 Jan 19] Available from: www.ahrq.gov/news/newsroom/press-releases/2015/cautitoolkit.html .
• 16. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. CUSP toolkit [cited 2016 Jan 19] Available from: www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.html .
• 17. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP) [cited 2016 Jan 19] Available from: www.ahrq.gov/research/data/hcup/index.html .
• 18. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey [cited 2016 Jan 19] Available from: http://meps.ahrq.gov/mepsweb .
• 19. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. About CAHPS [cited 2016 Jan 19] Available from: www.cahps.ahrq.gov/about-cahps/index.html .
• 20. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. National healthcare quality & disparities reports [cited 2016 Jan 19] Available from: www.ahrq.gov/research/findings/nhqrdr/index.html .
• 21. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. AHRQ quality indicators [cited 2016 Jan 19] Available from: www.qualityindicators.ahrq.gov .
• 22. Department of Health and Human Services (US) Agency for Healthcare Research and Quality. AHRQ announces grant opportunities to address opioid abuse disorder in rural areas [press release] 2015 Dec 8 [cited 2016 Jan 19] Available from: www.ahrq.gov/news/newsroom/press-releases/2015/opioid-abuse.html .
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Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) supports research to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

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Frequently Asked Questions

Check to find the answers to your questions about the Agency for Healthcare Research and Quality (AHRQ) programs and activities. You can search by category or key words. You can also send us your questions or website feedback here. We will respond to your requests based on the best available scientific evidence and research from our Agency.

AHRQ cannot provide diagnoses or specific medical advice to individuals on their personal health conditions and situations.

Ask a question, report a problem, or give us your opinion about a specific AHRQ program.

How can I access clinical practice guidelines online?

Clinical practice guidelines sponsored by the former Agency for Health Care Policy and Research, and released from 1992 through 1996, are available online from the National Library of Medicine through a full-text retrieval system. These guidelines are outdated due to more recent research findings or technological advances. Although these documents are no longer considered guidance for current medical practice, you may access them in the Clinical Practice Guideline Archive .

You may download these clinical practice guideline files for your personal use only. If you want to reproduce guidelines in any form, incorporate them into other computer access systems, or adapt or update content, copyright issues must be addressed.

For specific requirements and contacts, go to the Electronic User Policy and Copyright Information .

What role do nurses play in the quality of health care and patient safety efforts?

Nurses play a vital role in in implementing a culture of patient safety and generate a critical level of thinking that leads to faster and sustained practice transformation—not only in the hospital or ambulatory treatment facility, but also with community-based care and the care performed by family members. Optimizing the skills of nurses is essential in strengthening teamwork and communication to improve patient safety culture and patient safety practices.

For additional information, go to:

• Blog Post: Create Positive Change—Lead From the Middle .
• Blog Post: Emerging Infections: A National Patient Safety Challenge .
• Ricciardi, R. (2015). AHRQ Focuses on Ambulatory Patient Safety . J Nurs Care Qual 30(3), 193-196.
• Ricciardi, R., Moy, E., & Wilson, N. J. (2016). Finding the True North: Lessons From the National Healthcare Quality and Disparities Report. J Nurs Care Qual 31(1), 9-12. https://www.ncbi.nlm.nih.gov/pubmed/26599416 .

What is TeamSTEPPS and how can it improve patient safety in organizations?

TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is a teamwork system for health care professionals to improve communication and teamwork skills that was developed by the Department of Defense's Patient Safety Program and the Agency for Healthcare Research and Quality.

TeamSTEPPS provides ready-to-use materials and a training curriculum in a multimedia format with tools to help a health care organization plan, conduct, and evaluate its own team training program for higher quality, safer patient care.

For more information, go to: https://www.ahrq.gov/teamstepps .

How often should an organization administer the Surveys on Patient Safety Culture?

On average, hospitals that have submitted to the Hospital Survey on Patient Safety Culture Comparative Database more than once readminister the survey every 24 months. Although we do not provide any set recommendations regarding when to readminister the survey, we do caution against administering the survey less than 6 months apart. This would apply as well to the medical office, nursing home, community pharmacy, and ambulatory surgery center settings.

In deciding when to readminister the survey, it is important to consider the goal. Are you interested in monitoring your patient safety culture over time? Are you interested in assessing the impact of any specific efforts? If your goal is to assess a specific effort, then it is best to wait until all your training is complete and sufficient time has elapsed for the impact to take place and be relatively permanent (yet before other initiatives are started). If your goal is to monitor your culture over time, keep in mind that some change may or may not be a result of your specific effort and be aware of other initiatives that may have taken place since your original survey administration.

Why should a health care organization conduct a safety culture survey?

Safety culture surveys are useful for measuring organizational conditions that can lead to adverse events and patient harm in health care organizations. Organizations that want to assess their existing culture of patient safety should consider conducting a safety culture survey. Safety culture surveys can be used to:

• Raise staff awareness about patient safety.
• Elucidate and assess the current status of patient safety culture.
• Identify strengths and areas for patient safety culture improvement.
• Examine trends in patient safety culture change over time.
• Evaluate the cultural impact of patient safety initiatives and interventions.

What is the purpose of the Patient Safety and Quality Improvement Act of 2005 (PSQIA), Public Law 109-41?

The Patient Safety Act or PSQIA establishes a framework by which hospitals, doctors, and other health care providers may voluntarily report information to Patient Safety Organizations (PSOs), on a privileged and confidential basis, for the aggregation and analysis of patient safety and health care quality information.

The provisions of this law relating to the listing and operation of PSOs are administered by the Agency for Healthcare Research and Quality (AHRQ). The HHS Office for Civil Rights (OCR) is responsible for implementing the provisions regarding the interpretation, administration, and enforcement of the confidentiality protections and disclosure permissions.

For more information on the Patient Safety Act and how organizations can work with or become PSOs, go to the PSO website .

What are the Quality Indicators (QIs)?

The QIs of the Agency for Healthcare Research and Quality are a set of quality indicators organized into four "modules," each of which measure quality associated with processes of care that occurred in an outpatient or an inpatient setting. All four modules rely solely on hospital inpatient administrative data:

• Prevention Quality Indictors (PQIs)—or ambulatory care sensitive conditions—identify hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care.
• Inpatient mortality for medical conditions.
• Inpatient mortality for surgical procedures.
• Utilization of procedures for which there are questions of overuse, underuse, or misuse.
• Volume of procedures for which there is evidence that a higher volume of procedures maybe associated with lower mortality.
• Patient Safety Indicators (PSIs) also reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events.
• Pediatric Quality Indicators (PDIs) both reflect quality of care inside hospitals and identify potentially avoidable hospitalizations among children.

The detailed technical reports on the PQIs/IQIs and PSIs are available for download. Go to: https://www.qualityindicators.ahrq.gov/modules/Default.aspx

What areas of patient safety culture do the survey questions cover?

The Hospital Survey on Patient Safety Culture measures staff perceptions of patient safety culture in their work area/unit, as well as perceptions about patient safety culture in the hospital as a whole. The following 12 dimensions of patient safety culture are included, with each dimension measured by 3 or 4 survey questions:

• Communication openness.
• Feedback & communication about error.
• Frequency of events reported.
• Hospital handoffs & transitions.
• Hospital management support for patient safety.
• Nonpunitive response to error.
• Organizational learning—continuous improvement.
• Overall perceptions of safety.
• Supervisor/manager expectations & actions promoting patient safety.
• Teamwork across hospital units.
• Teamwork within units.

There are also two other questions that ask about:

• The patient safety "grade" the respondent would assign their work area/unit.
• The number of events the respondent has reported in the last 12 months.

The Nursing Home Survey on Patient Safety Culture emphasizes resident safety issues. It includes 42 survey items measuring 12 dimensions. Nine of the 12 survey dimensions are similar to those appearing in the Hospital Survey on Patient Safety Culture (HSOPS), although the items included in the dimensions are different. Three HSOPS dimensions were dropped from the nursing home survey: Frequency of event reporting, Teamwork across units, and Teamwork within units. Three new dimensions were added: Compliance with procedures, Training and skills, and Teamwork.

The dimensions in the nursing home survey are:

• Compliance with procedures.
• Feedback and communication about incidents.
• Management support for resident safety.
• Nonpunitive response to mistakes.
• Organizational learning.
• Overall perceptions of resident safety.
• Supervisor expectations and actions promoting resident safety.
• Training and skills.

In addition, the nursing home survey includes seven background demographic questions and two overall rating questions:

• Would they tell friends that this is a safe nursing home for their family?
• How would they rate this nursing home on resident safety?

The Medical Office Survey on Patient Safety Culture emphasizes patient safety and health care quality issues. The survey includes 51 items measuring 12 dimensions. Six of the survey dimensions (Communication Openness, Communication About Error, Organizational Learning, Overall Perceptions of Patient Safety and Quality, Owner/Managing Partner/Leadership Support for Patient Safety, and Teamwork) are similar to dimensions in the Hospital Survey on Patient Safety Culture, although the items are different in the two surveys. The remaining six survey dimensions are unique to the medical office survey with items that focus specifically on issues related to patient safety or quality of care in medical offices.

The dimensions in the medical office survey are:

• Communication about error.
• Information exchange with other settings.
• Office processes and standardization.
• Overall perceptions of patient safety and quality.
• Owner/managing partner/leadership support for patient safety.
• Patient care tracking/followup.
• Patient safety and quality issues.
• Staff training.
• Work pressure and pace.

In addition, the medical office survey includes three items about respondent background characteristics and two overall rating questions:

• How they would rate this medical office on five different areas of health care quality (patient centered, effective, timely, efficient, and equitable)?
• How they would rate this medical office on patient safety?

What is AHRQ's health information technology initiative?

AHRQ's health IT initiative is part of the Nation's strategy to put information technology to work in health care. By developing secure and private electronic health records for most Americans and making health information available electronically when and where it is needed, health IT can improve the quality of care, even as it makes health care more cost-effective.

The broad mission of AHRQ's health IT initiative is to improve the quality of health care for all Americans. The Agency has focused its health IT activities on the following three goals:

• Improve health care decisionmaking.
• Support patient-centered care.
• Improve the quality and safety of medication management.

How do I request a no-cost extension for my grant?

If your grant is under expanded authorities (in general, the following AHRQ grant activity codes are included under expanded authorities: F31, F32, K01, K02, K08, K18, K99, P20, R00, R01, R03, R13, R18, R21, R33, R24, R25, R36), the grantee institution has the authority to automatically extend the final budget period end date one time for a period of up to 12 months. Effective on August 1, 2020, AHRQ grant recipients may, and effective October 1, 2020, AHRQ grantee recipients must , use the No-Cost Extension feature in the eRA Commons to execute this extension. Read Notice NOT-HS-20-012 . Select to watch a tutorial on the standard process that an AHRQ grantee may follow to submit a one-time No Cost Extension in eRA Commons.

This action must be taken before the final budget period expires, using the No-Cost Extension (NCE) feature in the eRA Commons. Accessible from the eRA Commons “Status” screen, the link for the No-Cost Extension feature appears 90 days before the final budget period end date and closes at 11:59 p.m. on the final budget period end date. In extending the final budget period end date of the grant through the eRA Commons, the grantee agrees to update all required certifications, including human subjects and animal welfare, in accordance with applicable regulations and policies. An interim progress report and an interim FFR, reflecting programmatic progress and financial expenditures, respectively, through the original project end date, will be required to be submitted to the AHRQ GMS named on the most recent NOA no later than 90 days from the original project end date.

Grantees may not extend a project end date previously extended by AHRQ. Once the eRA Commons link is closed, a NCE becomes a prior approval request and must be submitted for consideration to the AHRQ Grants Management Specialist named on the most recent Notice of Award. Any additional final budget period end date extension beyond the one-time extension of up to 12 months requires AHRQ prior approval.

If your grant is NOT under expanded authorities (e.g. K12, P01, P30, P50, T32, U01, U13, U18, U19, and UC1, or any award for which the terms and conditions indicate either that the award is not under expanded authorities or that the award may not use the no-cost extension option under expanded authorities), the grantee institution must submit a written prior approval request, endorsed by an authorized institutional official, to the Grants Management Specialist named on the most recent Notice of Award. The request is to include a statement of why the extension is needed, the requested duration of the extension (not to exceed 12 months), research objectives to be completed during the extension period, and a detailed budget page and budget justification for the use of unobligated funds anticipated to remain at the end of the current budget period. No additional funds will be awarded for an extension. If the extension is approved, AHRQ will issue a revised Notice of Award reflecting the new project end date.

Whether under expanded authorities or not, an extension may only be made when no additional funds are required to be obligated by the awarding agency, there will be no change in the originally approved project scope or objective, and more time is needed to complete the research. The fact that funds remain at the expiration date of the project is not in and of itself sufficient justification for an extension. Conversely, if grant funds have been fully expended, an extension should not be requested/approved.

Please note that a request for a second no-cost extension can only be considered by AHRQ if the grantee can demonstrate that unusual circumstances occurred that prevented the project from being completed during the original extension period. An extension is considered a second extension even if the first extension was less than 12 months long.

Contact the assigned AHRQ Grants Management Specialist for details of what information needs to be included in a prior approval request for a second no-cost extension, which will include at a minimum: an explanation of the unusual circumstances warranting consideration of the request; strong programmatic justification of why it is crucial for the project to be extended further; progress to date; research objectives still to be completed; requested duration of second extension (not to exceed 12 months); the estimated unobligated balance expected to remain at the end of the first NCE, and a detailed budget and budget justification for use of these funds.

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2023 National Healthcare Quality and Disparities Report

• Copyright and Permissions

For the 21st year, AHRQ is reporting on healthcare quality and disparities. The annual National Healthcare Quality and Disparities Report is mandated by Congress to provide a comprehensive overview of the quality of healthcare received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. The report is produced with the help of an Interagency Work Group led by AHRQ.

• Collapse All
• Acknowledgments
• Portrait of American Healthcare: Key Findings
• Special Emphasis Topics: Key Findings
• Quality and Disparities Tables: Key Findings
• Resources To Improve Healthcare
• Demographics
• Leading Health Concerns
• Social Determinants of Health
• Healthcare Delivery Systems
• Hospitals Serving Communities That Experience Higher Risk for Poor Health Outcomes
• Hospital Bed Capacity
• National Healthcare Expenditures
• Geographic Variations in Care
• Biologic and Clinical Features of COVID-19
• COVID-19 vs. Influenza
• Post-COVID-19 Conditions
• COVID-19 Variants of Concern
• National Response to the COVID-19 Public Health Emergency
• Tracking COVID-19: National Measures of COVID-19 Activity
• NHQDR Special Emphasis Topics
• Factors Contributing to COVID-19 Mortality
• COVID-19 Vaccine Use
• Healthcare Delivery of COVID-19 Vaccines
• Healthcare Worker Use of COVID-19 Vaccines
• Disparities in COVID-19 Outcomes
• Discussion and Conclusions
• Inpatient and Emergency Department Visits With Confirmed COVID-19
• Patient Experience With Hospital Care
• Emergency Department Wait Times
• COVID-19 and Patient Safety
• Delayed Care Due to COVID-19
• Impact of COVID-19 on Diabetes Care
• Impact of COVID-19 on Cancer Screening
• COVID-19 Cases and Deaths in Nursing Homes
• Vaccines in Nursing Homes During the COVID-19 Pandemic
• Staff Shortages During the COVID-19 Pandemic
• Impact of Nursing Home Staff Shortages one Quality
• Appendix A. Methods of the National Healthcare Quality and Disparities Report and Related Chartbooks
• Appendix B. Quality Trends and Disparities Tables
• Appendix C. Measures Used for the State Quality and Disparities Maps
• Appendix D. Quality and Disparities Summary Charts
• Appendix E. Definitions and Abbreviations Used in the 2023 National Healthcare Quality and Disparities Report

Suggested citation:

2023 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; December 2023. AHRQ Pub. No. 23(24)-0091-EF.

This document is in the public domain and may be used and reprinted without permission. Citation of the source is appreciated.

• Cite this Page 2023 National Healthcare Quality and Disparities Report. Rockville (MD): Agency for Healthcare Research and Quality (US); 2023 Dec.
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