June 2014

VETERANS HEALTH ADMINISTRATION

NATIONAL CENTER FOR PATIENT SAFETY

PROPOSAL SOLICITATION: PATIENT SAFETY CENTERS OF INQUIRY

1) PURPOSE: This solicitation announces the opportunity for various entities of VHA 

to compete to become a Patient Safety Center of Inquiry (PSCI). Patient Safety 

Centers of Inquiry (PSCIs) are managed by the National Center for Patient Safety 

(NCPS) and are an integral part of the NCPS program. To be successful, a PSCI is 

expected to develop, disseminate, and, most importantly, implement clinically 

relevant innovations that improve patient safety in VHA facilities. Successful PSCIs 

will provide specific tools for the field that will help to improve patient safety. 

2) POLICY: Nine PSCIs are currently funded through the end of FY 2015. Starting 

with FY 2016, VHA NCPS will fund multiple PSCIs, each for a three year period. 

Current PSCIs must re-compete along with other facilities for FY 2016 funding. 

Total annual costs proposed for a single PSCI cannot exceed $290,000 per year. 

Those developing proposals are encouraged to submit proposals for less than 

$290,000 per year; cost will be a factor in the selection process. Each PSCI’s 

accomplishments will be evaluated at the end of each fiscal year as a condition of 

continued funding. Based on the availability of funds and satisfactory completion of 

the work proposed for the initial course of funding, PSCIs would be able to apply for 

continued funding. 

3) BACKGROUND: PSCIs were first funded beginning in 1999 and have made 

valuable contributions to the improvement of patient safety within VHA and beyond. 

For example, the PSCIs have contributed to teamwork and simulation training; the 

application of usability testing and human factors design to Bar-Code Medication 

Administration. They have designed and lead Breakthrough Series Collaboratives to 

reduce patient falls, adverse drug events, and improve safety in high-risk settings. 

There has been extensive work in the areas of safe patient handling and movement 

and patient fall prevention and management; and far-reaching studies of fatigue and 

its effects on clinicians’ performance. They have focused on improvement in the 

safety of drug prescribing practices and medication administration, providing 

interventions to decrease preventable ADEs, including medication reconciliation and 

reduction in medication errors related to ordering of chemotherapy for treatment of 

malignancy. More recently PSCIs have focused on improving electronic 

communication and alerts, improving patient safety during moderate sedation, 

improving home safety for high-risk patients as well as using human factors 

principles to reduce hospital acquired infections and improve the sterilization of 

reusable medical equipment. PSCI’s have also focused on suicide prevention, patient 

safety measurement, diagnosis and treatment of delirium and interventions to reduce 

catheter associated urinary tract infections. 

4) PROPOSAL EXPECTATIONS:

PROPOSAL SOLICITATION: PATIENT SAFETY CENTERS OF INQUIRY 1 
a) Goals and Objectives: Proposals for PSCIs should aim to evaluate and translate 

patient safety research findings into standard practices that are disseminated and 

implemented to improve patient safety across the entire VHA system. Funded 

PSCIs will be able to work with NCPS staff to develop promising pilot tests and 

other projects to determine how to best translate facility-level corrective actions 

into practices that could be applied successfully elsewhere in the VHA to improve 

patient safety. Each PSCI is expected to: 

i) Develop, implement, and demonstrate interventions in multiple VHA facilities 

to promote practices that improve patient safety by reducing adverse events or 

that replace or improve practices known to be associated with patient safety 

problems. 

ii) Document that changed practices and/or systems reduce the likelihood of 

adverse events in multiple VHA facilities. 

iii) Document the methods employed to foster changing practices and systems so 

that other VHA facilities can implement similar or identical changes to 

improve patient safety. 

iv) Develop, test, refine, and facilitate active distribution of tools and products 

specifically designed to promote patient safety, such as clinical tools; 

cognitive aids; educational materials; measures of patient safety, policy 

reports; VHA information letters, handbooks, and/or directives; and others. 

Tools and other output should be evaluated for effectiveness and impact. 

b) Areas for Focus: NCPS has studied the patient safety literature and the RCAs 

submitted from VHA facilities to identify areas in health care where contributions 

from new PSCIs are most needed. The following topics and areas of study (listed 

alphabetically) are those identified by NCPS as high priority topics for PSCIs 

(other topics will be considered but applicants must justify why this area is a high 

priority area for VHA): 

i) Delirium: assessment and treatment

ii) Falls prevention and falls injury prevention 

iii) Improving safe prescribing of Opioids 

iv) Improving safety of clinical alarm systems (NPSG 06.01.01) 

v) Infection control and the prevention of hospital acquired infections. 

vi) New Measures of Patient Safety

vii)Outpatient care/ambulatory care safety improvement

viii) Patient hand-offs and transitions of care 

ix) Preventing adverse drug events

x) Prevention of Serious Reportable Events or “Never Events” 

xi) Reduction in diagnostic error 

xii)Reduction of delays in treatment and diagnosis 

xiii) Suicide prevention 

xiv) Wound healing and the prevention and treatment of pressure ulcers. 

xv) Use of human factors engineering principles to improve patient safety 

5) REQUIREMENTS:

PROPOSAL SOLICITATION: PATIENT SAFETY CENTERS OF INQUIRY 2 
a) General Requirements: Leadership and responsibilities for operational success 

should be clearly located at one site; however, PSCIs should plan to spread 

innovations to other facilities within VHA. Proposals may originate from any 

VHA facility but must be coordinated and approved by appropriate facility 

leadership and the Network Director.

b) Proposal Requirements: 

i) Administrative Content. Proposals must contain the following information in 

numbered order and are to be no more than 20 pages in length, excluding a

two-page executive summary, transmittal letter, and appendices. Applications 

should be typed on standard-sized (8 l/2 by 11 inch) white paper, singlespaced, with a font size no smaller than twelve characters per inch. 

Applications should include: 

(1) Executive Summary of overall proposal and implementation plans 

(maximum two pages).

(2) Patient safety topic(s) to be emphasized and rationale for their selection.

(3) Specific PSCI goals and objectives.

(4) Plans and schedules for attaining, evaluating, and documenting the 

achievement of the PSCI’s goals and objectives. 

(5) Proposed administrative infrastructure, including key leadership and core 

staff roles and pertinent qualifications. The PSCI is expected to have a 

Director who will allocate at least 40% effort to running the center. 

(6) Description of any proposed collaborative relationship, e.g., with 

academic affiliate or other organization that has a demonstrated record of 

successful activity in technical or programmatic areas fundamental to 

patient safety, or key offices in VACO that can help to track and 

disseminate your finding and products. 

(7) Any proposed advisory mechanisms, their composition, functions, and 

operational activities.

(8) Discussion of applicant’s (site and key personnel) experience and 

evidence of success in applying patient safety innovations or other 

achievements in improving the quality or safety of patient care. It is 

especially important to list past experience developing and implementing 

patient safety programs. 

(9) Summary of specific milestones for organizational progress and 

accomplishments, beginning with the selection of the PSCI (anticipated no 

later than December 30, 2014) and ending with the close of the proposed 

funding period. (Include Gantt chart for clarity of anticipated 

accomplishments).

(10) Personnel and budget. PSCIs will be funded under the 0152 

Medical Support and Compliance appropriation (preferred), the 0160 

Medical Services appropriation, or a combination of the two. Requested 

funding must be broken down by appropriation, purpose, and FY quarterly 

apportionment for each year as follows: 

APPROPRIATION PURPOSE Q1 Q2 Q3 Q4 TOTAL

PROPOSAL SOLICITATION: PATIENT SAFETY CENTERS OF INQUIRY 3 
0152 MS&C Salaries 

0152 MS&C All Other

0160 Med Services Salaries

0160 Med Services All Other

TOTAL

(NOTE: If you plan to initiate a contract for any reason, please contact David 

Davis at 802-291-6285 or “david.davis5@va.gov” prior to submitting your funding 

breakdown. 

RESTRICTIONS:

(a) PSCI funds cannot be used for travel. No travel obligations may be 

made at the local level from any PSCI funds that originate from the 

National Center for Patient Safety. Travel will, in almost all cases, 

need to be funded by the host medical center from medical center 

funds. NCPS anticipates it will have a limited ability to directly 

support/fund mission essential temporary duty travel for PSCIs in FY 

2016; however, the call for PSCI travel requests is unlikely to be 

released prior to the end of December 2015. 

(b) PSCI funds cannot be used for IT equipment, software, or IT services. 

Gantt chart of activities for duration of funding 

NOTE: It is strongly recommended that the servicing Fiscal office be consulted 

for a determination of which appropriation(s) funds are requested under. Once 

initial funding commitments are made, it may not be possible to change the 

appropriation. 

(11) Gantt chart of activities for duration of funding 

c) Appendices should include only: 

i) Biographical sketches of key personnel. 

ii) Letters of support (e.g., from important component participants and/or 

consultants if applicable). Letters of support from elected officials should not 

be solicited or submitted.

iii) Related publications by key personnel proposed. 

6) Signatures. Each proposal should include cover transmittal letter(s) approved and 

signed by the appropriate facility Directors. Evidence of coordination among 

involved parties also is required. 

7) Due Date. Proposals must be received no later than September 5, 2014. Prior to 

proposal submission, applicants should submit a one-page letter of intent 

summarizing the basic technical emphasis of their application, principle investigators 

and collaborators, VA and university affiliation, no later than August 8, 2014 (see 

Email address noted below). This letter will be used only to organize the proposal 

review process and need not be signed by a facility Director. Submitting this letter 

does not commit a prospective applicant to submit a proposal. 

PROPOSAL SOLICITATION: PATIENT SAFETY CENTERS OF INQUIRY 4 
a) Proposal Submission. An unbound original and an electronic copy of each

application are to be submitted:

Peter D. Mills Ph.D.

Attn: Patient Safety Centers of Inquiry

VAMC (10A 4E)

215 North Main Street

White River Junction, VT 05009

(Telephone number: 802 291 6285)

(Email: Peter.Mills@va.gov )

8) PROPOSAL REVIEW PROCESS: A committee of experts in patient safety and/or 

quality improvement will review the proposals. After the review period, a statement 

summarizing the review of their proposal will be provided to each applicant and 

submitting Network. Review criteria will emphasize:

a) Technical merit of the goals, objectives, plan, and relevance to NCPS priorities 

for PSCIs, as described above in Paragraph 4 of this solicitation. Authors should 

be sure to demonstrate current knowledge of the state of scientific and technical 

knowledge in their selected topic through citation of relevant research findings. 

(40%)

b) Feasibility of implementation of the proposed work of the PSCI throughout VHA 

facilities. This factor may include an assessment of the prior work, productivity, 

and qualifications of the proposed key personnel. (30%)

c) Administrative management plan. This will take into account the appropriateness 

of proposed administrative infrastructure; organizational and advisory support; 

and the plans and schedule for attaining, evaluating, and documenting the 

achievement of the PSCI’s goals and objectives. (10%)

d) Value to the VHA as part of a PSCI portfolio, as defined by (a), (b), and (c) above 

and the proposed annual and/or total cost of the proposed PSCI. (20%)

e) It is important to note that in order to reduce the possibility of conflict; we select 

most of our reviewers from outside the VA system, so references to internal VA 

programs and mechanisms should be clearly explained. 

Note: The process will be managed by the Director of the Field Office, National Center 

for Patient Safety. Questions may be addressed to Dr. Peter Mills, Director, Field Office,

National Center for Patient Safety, by e-mail or at (802) 295-9363 ext. 6567.

There will be calls on June 12th at 1:00 EST and August 13th at 1:00 EST to answer 

any questions. Number: 800-767-1750 CODE: 28203.

PROPOSAL SOLICITATION: PATIENT SAFETY CENTERS OF INQUIRY 5