This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
Please go to www.ahrq.gov for current information.
National Guideline Clearinghouse™ (NGC)
The National Guideline Clearinghouse™ (NGC), an Internet resource for evidence-based clinical practice guidelines located at http://www.guideline.gov, has now been operational for 3 years. The NGC was developed by AHRQ, in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP), to be a resource for physicians, nurses and other health care professionals.
NGC has more than 1,000 clinical practice guidelines submitted by over 165 health care organizations and other entities. New guidelines are being added to NGC weekly.
Over the last 3 years, NGC has had over 4 million visitors, processed over 40 million requests, and received over 81 million hits. NGC now has over 46,000 visits a week.
AHRQ does not require users of the National Guideline Clearinghouse™ to register in order to use the site. However, AHRQ recently completed the second customer satisfaction survey of NGC which does provide some insight into who uses the site. Physicians represented the largest portion of survey respondents (40.6 percent) followed by nurses and/or nurse practitioners (18.9 percent). 93.5 percent of respondents rated their overall satisfaction with NGC as either "fairly satisfied" or "very satisfied" compared with 89.1 percent for the First Annual Survey. Respondents to the survey also provided many useful comments on how they used it in their clinical work. For instance, a number of respondents reported using NGC to identify guidelines for adaptation in their health system or institution and a desire to find the best approach to treating their patients.
The University of Michigan Health System (UMHS) in Ann Arbor has developed a program entitled Guidelines Utilization, Implementation, Development and Evaluation Studies (GUIDES). Now in its sixth year, UMHS has 10 of its guidelines in the National Guideline Clearinghouse™ (NGC).
"We consider the NGC a wonderful enhancement to our existing processes, and this is true across the spectrum of activity. The NGC is especially valuable in disseminating our work to colleagues in other institutions, and the variety of users is impressive. We have received inquiries from all over the world, and from a range of organizations," states Dr. Renee Stiles, Ph.D., project manager, GUIDES.
Clinical Preventive Services
AHRQ links prevention research with clinical practice by sponsoring the U.S. Preventive Services Task Force (USPSTF) and the Put Prevention Into Practice (PPIP) program. The Task Force synthesizes the evidence-base and the PPIP program promotes the application of the Task Force results.
The U.S. Preventive Services Task Force (USPSTF)
The U.S. Preventive Services Task Force (USPSTF) is a critical source of information on what does and does not work in the health care system specific to prevention. First convened in 1984, the USPSTF is an independent panel of preventive health experts, charged with evaluating the scientific evidence for the effectiveness of a range of clinical preventive services—including common screening tests, immunizations, counseling for health behavior change, and chemoprevention—and producing age- and risk-factor-specific recommendations for these services.
The third USPSTF was convened in early FY 1999 and began work on 12 initial topics selected by Task Force members based on preliminary work by two of AHRQ's Evidence-based Practice Centers: the Research Triangle Institute/University of North Carolina at Chapel Hill and the Oregon Health Sciences University.
In FY 2001, the third USPSTF issued its first four updated recommendations covering chlamydia screening, lipid screening, skin cancer, and bacterial vaginosis.
Chlamydia screening. The Task Force continued to recommend that primary care clinicians screen all sexually active women ages 25 and younger for chlamydia, as well as older women who are at risk for chlamydia, as part of regular health care visits.
Chlamydia is the most common bacterial sexually transmitted disease in the United States, with an estimated 3 million new cases each year. Most women have no symptoms when initially infected, but if they go untreated, they can develop pelvic inflammatory disease, infertility, and other serious health problems, including increased risk of HIV infection. Treatment with antibiotics is easy and effective.
Lipid screening. In a broadening of its 1996 recommendations, the USPSTF recommended that regular screening for high blood cholesterol and other lipid abnormalities, which can lead to coronary heart disease, should not have an upper age limit (previously set by the panel at age 65). The USPSTF also issued a new recommendation calling for the screening of younger adults for lipid abnormalities beginning at age 20 if they have risk factors for coronary heart disease such as diabetes, family history of heart disease, tobacco use, or high blood pressure. In addition, the panel revised its 1996 statement to recommend that for initial screening purposes, clinicians measure high density lipoprotein (HDL) cholesterol along with total cholesterol.
Skin cancer. The Task Force concluded, based on its most recent review of the literature, that there is still insufficient scientific evidence to determine whether regular total body skin examination for skin cancer is effective in reducing illness and death. This is the same conclusion the Task Force reached in 1996.
Bacterial vaginosis. Bacterial vaginosis is a common condition among women of childbearing age that results in a vaginal discharge caused by an imbalance in vaginal bacteria. Despite research showing that pregnant women with bacterial vaginosis have a higher risk of preterm delivery, the Task Force has concluded that the evidence does not merit regular screening for bacterial vaginosis in all pregnant women as an effective way to reduce the incidence of preterm delivery. For women at high risk due to a previous preterm delivery, however, the USPSTF found conflicting results regarding the benefit of screening and treatment and concluded that these options be left to the discretion of clinicians.
12 Initial USPSTF Topics
- Chemoprevention (for example, tamoxifen and related drugs) to prevent breast cancer (new topic).
- Vitamin supplementation to prevent cancer or coronary heart disease (vitamin E, folate, beta carotene, and vitamin C) (new topic).
- Screening for bacterial vaginosis in pregnancy (new topic).
- Developmental screening in children (new topic).
- Screening for diabetes mellitus (updated topic).
- Newborn hearing screening (updated topic).
- Screening for skin cancer (updated topic).
- Counseling to prevent unintended pregnancy (updated topic).
- Screening for high cholesterol (updated topic).
- Postmenopausal hormone therapy (updated topic).
- Screening for chlamydial infection (updated topic).
- Screening for depression (updated topic).
Put Prevention Into Practice
AHRQ's Put Prevention Into Practice (PPIP) program helps translate the evidence-based recommendations of the U.S. Preventive Services Task Force into practice through the development and dissemination of resources for providers, patients, and office systems. PPIP emphasizes the importance of a comprehensive, system-wide, team approach to delivering effective preventive interventions. AHRQ works closely with public and private partners to disseminate PPIP resources.
PPIP materials include information on preventive services recommendations; an implementation guide, including flowsheets and other forms; and personal health guides for children, adults, and people over 50.
Select for PPIP Tools & Resources.
During FY 2001—in conjunction with the release by the third USPSTF of its recommendations on screening for chlamydia, lipid disorders, bacterial vaginosis in pregnancy, and skin cancer—work was completed on a new information kit, What's New in Clinical Prevention? The kit includes factsheets on the newly released topics and other information to promote the Task Force and PPIP. A prevention LISTSERV® was also developed.
During FY 2001, work was completed on A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach. The guide describes easy to follow, logical steps to develop a formal system for delivering clinical preventive services. It is based on scientific and empirical evidence and has been found effective in many settings. The new guide:
- Breaks the process into small, manageable tasks.
- Provides tools for tracking the delivery of preventive care, such as flowsheets and health risk profiles.
- Includes worksheets and templates.
- Identifies resources for more information.
In FY 2001, AHRQ invested $5 million into bioterrorism-related research.
Examples of products and tools that are currently or soon will be available include the following:
- Researchers at the University of Alabama at Birmingham and Research Triangle Institute have developed Web-based training modules to teach health professionals how to address varied biological agents. Separate modules exist for ER practitioners, radiologists, pathologists, and infection control specialists. These clinicians can obtain continuing medical education (CME) credit at this site located at http://www.bioterrorism.uab.edu.
- Through collaborations with the University of Maryland, Emory University, District of Columbia Hospital Association, and Booz-Allen Hamilton, a questionnaire has been developed that can help assess the current level of preparedness of hospitals or health systems and their capacity to respond to bioterrorist attacks. The Department of Defense is already using this assessment in pilot work.
- In collaboration with the New York City Department of Health and the Mayor's Office of Emergency Management, AHRQ's Integrated Delivery System Research Network based at the Weill Medical College of Cornell University has developed a computer simulation model for city-wide response planning for bioterrorist attacks. This model for mass prevention of disease in the event of a bioterrorist attack will be validated by a live exercise funded by the Department of Justice.
- Researchers at the Children's Hospital of Boston are exploring the feasibility of building decision support models for information systems using linked health care data. These information systems would help to link the public health infrastructure with the clinical care delivery system to speed reporting and enhance rapid dissemination of relevant information. A preliminary product is a literature review that clarifies the potential of Web-based systems for clinicians to obtain timely information and report potential bioterrorist events to public health authorities.
- Researchers at the University of Pittsburgh and Carnegie-Mellon are continuing development on a "Real-time Outbreak and Disease Surveillance (RODS) System" for bioterrorist events. The purpose of RODS is to provide early warning of infectious disease outbreaks, possibly caused by an act of bioterrorism, so that treatment and control measures can be initiated to protect and save large numbers of people.
- The Science Applications International Corporation (SAIC) in collaboration with Johns Hopkins University, George Washington University, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has completed extensive work on assessing and recommending improvement in the linkages between the medical care, public health, and emergency preparedness systems to detect and respond to bioterrorist events.
- AHRQ's User Liaison Program is planning an audio teleconference in January 2002 for State and local health policymakers to inform them of related research findings that could help them assess and strengthen the capacity of the health care system within their jurisdictions to respond to bioterrorism.
- The Primary Care Practice-Based Research Network at the University of Indiana is using a city-wide electronic medical records system as a model for surveillance and detection of potential bioterrorism events across a wide range of health care facilities, including primary care practices, public health clinics, emergency rooms, and hospitals.
Return to HCQO Contents
Strengthen Quality Measurement and Improvement
AHRQ's second research goal includes developing and testing measures of quality, as well as studies of the best ways to collect, compare, and communicate these data, and identifying and widely disseminating effective strategies to improve quality of care. To facilitate the use of this information in the health care system, the Agency focuses on research that determines the most effective ways to improve health care quality, including promoting the use of information on quality through a variety of strategies, such as information dissemination and assessing the impact on health care organization and financing.
Measuring and Improving the Quality of Health Care
Millions of Americans receive high-quality health care services. The United States has many of the world's finest health care professionals, academic health centers, and other research institutions. However, an Institute of Medicine (IOM) report examining cancer care found that quality problems occur across all types of cancer care and in all aspects of the process of care. Crossing the Quality Chasm summarized problems with breast cancer care include "underuse of mammography for early cancer detection, lack of adherence to standards for diagnosis, inadequate patient counseling regarding treatment options, and underuse of radiation therapy and adjuvant chemotherapy following surgery."
IOM Report, Crossing the Quality Chasm, states:
"Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm."
In FY 2002, AHRQ has called for applications which examine two different aspects of quality. The first Program Announcement (PA) seeks to fund research to better understand the impact of payment and organization on quality. AHRQ has already funded a grant in FY 2002 based on this program announcement. This grant, "Hospital Finances and the Quality of Hospital Care" will look at the relationship between a hospital's financial condition, its operational and resource allocation decisions, and the quality of clinical care at that hospital. Since many hospitals and provider organizations in the United States are facing significant financial constraints, it is important to understand the impact of financial conditions on operational decisions.
The second PA with a quality dimension is Translating Research Into Practice (TRIP). There are many important questions about how to translate research findings into improvements for patients and consumers, clinicians and health care delivery systems and policy makers. While many strategies have been developed to translate research into practice, developing new methodologies and evaluating which existing methodologies have the most meaningful impact on quality of care is a priority for all of AHRQ's research. By translating research into practice, this part of AHRQ's investigator-initiated portfolio will complete the research pipeline and yield more immediate improvements in Americans' health care. Recent and ongoing research is providing important insights regarding translation of evidence-based programs into practice, most often for individuals with specific clinical conditions (e.g., children with asthma, diabetes), and efforts to assess quality of care now provide both a stimulus for change and benchmarks for improvement.
Recent accomplishments: Thousands of Medicare patients with diabetes mellitus or atrial fibrillation can benefit from two new quality improvement tools developed with support from AHRQ. The test results for these tools were published in two articles in the June 13, 2001, issue of the Journal of the American Medical Association. Findings from a third AHRQ-funded study in the same issue can improve care at the end of life by encouraging more end-of-life discussions between HIV patients and their doctors.
In the diabetes study, University of Alabama at Birmingham researchers found that physicians who received periodic feedback reports based on chart reviews of their care of Medicare fee-for-service patients with diabetes mellitus, plus performance goals called "achievable benchmarks of care," significantly outperformed similar doctors who received only the chart reviews and standard performance feedback. Patients of doctors who were provided the benchmarks had 33 percent to 57 percent higher odds of receiving long-term glucose control measurement, serum cholesterol testing, foot exams and influenza vaccinations than patients of the other physicians. Achievable benchmarks of care are standards of excellence attained by top performers among peer physicians, which provide a reference for doctors to assess their own performance.
In the atrial fibrillation (AF) study, researchers found that their new CHADS2 method for predicting risk of stroke in patients with this condition is more accurate than existing methods. CHADS2 is an acronym for the risk factors for stroke in patients with AF - congestive heart failure, hypertension, advanced age, diabetes and a prior stroke. While physicians agree that warfarin therapy is favored when the risk of stroke is high, and aspirin when it is low, there has been little agreement on how to predict the risk of stroke. By more accurately estimating the risk of stroke in a patient with AF, doctors and their patients can make better decisions about which anti-thrombotic therapy to use. CHADS2 may be especially helpful for identifying low-risk patients who, by taking aspirin, can avoid the office visits, expense and risks of taking warfarin, which has to be closely monitored because of its higher risk of causing bleeding. AHRQ will work with Medicare and the private sector to promote the use of these tools in practice.
The third AHRQ-funded study in the June 13 issue of JAMA found that half of all HIV-infected persons in the United States, and especially-African Americans, Hispanics, intravenous drug users, and less well educated individuals, never talk about end-of-life care with their doctors. Such discussions could result in better understanding by physicians of what types of care patients desire when they are very ill and close to death. In addition, discussions may lead to a patient designating a surrogate to make decisions if he or she is unable to do so. These approaches could greatly improve the experience of deaths for patients and their caregivers.
Patient Safety and Reducing Errors in Medicine
The November 1999 report of the Institute of Medicine (IOM), To Err is Human: Building a Safer Health System, focused a great deal of attention on the issues of medical errors and patient safety. The report indicated that as many as 44,000 to 98,000 people die in hospitals each year as at the result of medical errors. Even using the lower estimate, this would make medical errors the eighth leading cause of death in this country.
More people die annually from medical errors than from automobile accidents (43,458), breast cancer (42,297), or AIDS (16,516). It is estimated that about 7,000 people each year die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries.
Although the increased public attention on this issue is a recent phenomenon, AHRQ has recognized for some time that reducing medical errors is critically important for improving the quality of health care. In 1993, the agency published one of the first reports focused on medical errors. This landmark report noted that 78 percent of adverse drug reactions were due to system failures, such as the misreading of handwritten prescriptions. Subsequent studies sponsored by the agency have focused on the detection of medical errors, investigation of diagnostic inaccuracies, the relationship between nurse staffing and adverse events, computerized adverse drug event monitoring, and computer-assisted decisionmaking tools to reduce the potential for errors and improve safety.
Americans have a very real fear of medical errors. According to a National poll conducted by the National Patient Safety Foundation:
- 42 percent of respondents had been affected by a medical error, either personally or through a friend or relative.
- 32 percent of the respondents indicated that the error had a permanent negative effect on the patient's health.
In FY 2001, AHRQ invested $50 million in 94 new research grants, contracts, and other projects to reduce medical errors and improve patient safety. This effort represents the Federal Government's largest single investment in research on medical errors. These projects will address key unanswered questions about when and how errors occur and provide science-based information on what patients, clinicians, hospital leaders, policymakers, and others can do to make the health care system safer.
The results of this research will identify improvement strategies that work in hospitals, doctors' offices, nursing homes, and other health care settings across the Nation. AHRQ's $50 million investment is the first phase of a multi-year effort; AHRQ was appropriated $55 million for patient safety in FY 2002.
The six major categories of AHRQ's FY 2001 patient safety initiative are provided in the following box.
FY 2001 Patient Safety Initiative Categories
Identifying methods for reporting medical errors data. This involves 24 demonstration projects to study different methods of collecting data on errors or analyzing data that are already collected to identify factors that put patients at risk for medical errors.
Using computers and information technology to prevent medical errors. This group of 22 projects will develop and test the use of computers and information technology to reduce medical errors, improve patient safety, and enhance quality of care.
Understanding the impact of working conditions on patient safety. These eight projects will examine how staffing, fatigue, stress, sleep deprivation, and other factors can lead to errors.
Developing innovative approaches to improving patient safety. This involves 23 projects that will research and develop innovative approaches to improving patient safety at health care facilities and organizations in geographically diverse locations across the country.
Disseminating research results. This group of 7 projects will focus on educating clinicians and others about the results of patient safety research. This work will help develop, demonstrate, and evaluate new approaches to improving provider education in order to reduce errors, such as applying new knowledge on patient safety to curricula development, continuing education, simulation models, and other provider training strategies.
Additional patient safety research initiatives. AHRQ funded 10 additional projects covering other patient safety research activities, including supporting meetings of State and local officials to advance local patient safety initiatives and assessing the feasibility of implementing a patient safety improvement corps.
Recent Accomplishment: In July 2001, AHRQ released new evidence on practices that can improve patient safety throughout the nation's health care system. The evidence report, compiled by the Evidence-based Practice Center at the University of California San Francisco/Stanford University, reviewed the evidence on a total of 79 patient safety practices. It lists 73 that are likely to improve patient safety and describes 11 that the researchers considered highly proven to work but are not performed routinely in the nation's hospitals and nursing homes. The report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, is the result of a comprehensive review of the literature from medicine, aviation, and other relevant fields.
Among the 11 highly proven practices are giving patients antibiotics just before surgery to prevent infections, using ultrasound to help guide the insertion of central intravenous lines and prevent punctured arteries and other complications, and giving surgery patients beta blockers to prevent heart attacks during or after the operation. Some practices are not included because they lack sufficient testing to be considered highly proven or they carry important potential risks. These include the increasing use of antibiotics to prevent infections, which has the potential to create antibiotic resistance. The report also is being provided to members of the National Forum for Health Care Quality Measurement and Reporting (NQF), which includes consumers, public and private purchasers, employers, health care providers, accrediting bodies, and organizations involved in health care research or quality improvement. The NQF plans to use this information to develop a list of measures that patients throughout the nation can use to determine the actions that hospitals and/or health care facilities can take to improve safety.
Progress Toward a National Report on Quality
AHRQ is developing the first-ever annual report on the quality of health care in the United States, as called for in AHRQ's reauthorization legislation, which became law in December 1999. The goal of the report is to provide a clear, easily understood picture of the quality of health care in America and to highlight areas where improvement is needed. The development of a national report on health care quality is an important step in improving the quality of the Nation's health care system.
The project is being led by AHRQ with collaboration from the National Center for Health Statistics. An interagency work group will develop the final content and design of the report. Other members of the work group include the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration.
Work on the National Quality Report (NQR) is proceeding in four areas:
- Developing a conceptual framework for reporting.
- Identifying potential measures to populate the framework.
- Identifying data sources for potential measures.
- Conducting audience research on report design.
Conceptual framework. AHRQ commissioned a study with the Institute of Medicine (IOM) to work on a conceptual framework for the NQR. The IOM formed a 14-member committee of leading experts in quality and quality measurement, chaired by Dr. William Roper. The committee heard testimony from a wide variety of groups, including: the National Forum for Healthcare Quality Measurement and Reporting, Foundation for Accountability, National Committee for Quality Assurance, Joint Commission on Accreditation of Healthcare Organizations, American Medical Accreditation Program, leading academic researchers, and international experts.
The committee has completed its work and recommended a conceptual framework that includes both dimensions of care (e.g., safety, effectiveness, patient centeredness, timeliness, equity) and patient needs (e.g., staying healthy, getting better, living with illness, coping with the end of life). The quality monitoring system developed for the NQR will be organized around this framework.
Measures. AHRQ has formed an interagency workgroup to identify candidate measures for the report. This workgroup reviewed measures included in existing quality measurement systems. This was supplemented by a multi-step "call for measures" that was sent to all relevant Federal agencies. The IOM initiated a complementary call for measures to the private sector. Measures identified through these processes form a pool of candidate measures for the report. The IOM identified a set of criteria to use to evaluate candidate measures, which includes: importance, scientific soundness, and feasibility. The workgroup is evaluating the candidate measures using these criteria, with the aim to populate the framework for reporting developed by the IOM. We anticipate that there will be adequate measures for some dimensions of the framework, but that measures will be sparse for others. Areas where measures are sparse will help define AHRQ's future research agenda in quality measurement.
Data sources. AHRQ has started efforts to identify existing data sources that might be used to support the NQR. Potential sources fall into several categories, including:
- Population-based data collection efforts.
- Establishment/provider-based data collection efforts.
- Administrative/regulatory data collection efforts.
- Vital statistics.
- Surveillance activities.
AHRQ also is modifying existing data sources to better support the NQR. For example, AHRQ is enhancing the Medical Expenditure Panel Survey by increasing the size and geographic dispersion of the sample and adding quality-related content. We anticipate that the first NQR will rely heavily on existing Federal databases. As time goes on, private data sources will likely take on added importance. We have begun a project looking at private sector data that may be appropriate for the report.
Audience research. AHRQ will be conducting research to identify the needs of potential audiences for the report and to develop a report design to meet those needs. There will be several rounds of research, including testing on general design, report organization, measure selection, and presentation format. AHRQ also initiated a project to review existing reporting systems to inform the development of the NQR. The purpose of the effort is to conduct a comprehensive literature search for information on quality reporting programs in the United States and internationally. The information will be analyzed to identify common themes and best practices among other reporting entities. This input will be used to help design the NQR prototypes that go to audience testing.
The focus of initial audience research for the NQR is on written products (a short report to Congress that highlights important findings and technical appendices that include detailed tables, the specifics of our methodology, etc.). As time goes on, we plan to develop a Web-based product that will allow users to drill down from national-level data to obtain detail on quality performance measures for population subgroups and smaller geographic areas (e.g., regions, States).
Healthcare Working Conditions on the Quality of Care
Increasing our understanding of how working conditions affect health care workers, the risks for errors, and the quality of services provided to patients is of major importance to the health care industry. Recent efforts to reduce costs and streamline the delivery of care have led to significant changes in the health care workplace. The experiences of other industries demonstrate that differences in the equipment and physical characteristics of the workspace, changes in work responsibility and process, and differences in staffing levels can affect the quality of the products or services provided. For example, research on working conditions in the aviation industry has provided evidence of the relationship between aviation safety and work hours, including the effect of factors such as fatigue, lack of sleep, and shift work.
Despite the importance of these factors, there has been scant research focused on the importance of the quality of the workplace environment—not only for worker satisfaction, worker health, and the avoidance of disability, but also for the quality and productivity of the work performed. Workplace factors, including the way work is organized and staffed, may pose a threat, not only to the health and well-being of workers, but also to the quality of care they provide to patients and the safety of the patients.
In FY 2001, AHRQ funded over 30 projects that will examine the effects of working conditions on health care workers' ability to provide safe, high-quality care in ambulatory, inpatient (both hospital and long-term care institutions), and home care settings. Examples of the critical issues to be addressed include:
- Effects of extended work hours, sleep deprivation and fatigue, and stress on residents and nurses working in hospital-based settings.
- Relationship between working conditions—such as nurse to patient ratios, workload, and skill mix—and the occurrence or near occurrence of medical errors or adverse events.
- Impact of workplace characteristics, organizational culture, and teamwork on the safety, quality, and outcomes of care in inpatient settings, specifically intensive care units and surgical settings.
- Relationship between nursing home working conditions—such as staffing levels, job design, and job satisfaction—and worker outcomes, patient outcomes, and quality of care.
- Impact of financial incentives and the work environment on the quality of care in both ambulatory and inpatient settings.
- Effects of employee training, satisfaction, and understanding of patient safety on patient outcomes and quality of care.
Select for CAHPS® Fact Sheet.
Return to HCQO Contents
Proceed to Next Section