Download a Microsoft Word copy of this form to my desktop

AHC Fairview Joint Funding
Application Number:________________

 
AHC-FAIRVIEW JOINT FUNDING PHASE 2 APPLICATION FORM

Use this space to expand upon the objectives listed on the Phase 1 application form:

   

 

Use this space to expand upon how the proposed activity will meet the above stated objectives:

 
 

For Questions 1 — 4, you need only answer the questions that apply to the primary objective of the proposed activity. For example: Answer # 1 if this activity is RESEARCH, answer #2 if this activity is EDUCATION, #3 if it is CLINICAL and # 4 if it is best described as something other than a specifically research, education or clinical activity.
 

1.  If this RESEARCH project is funded:
 

a) Will this proposed activity set the stage for additional activity?                     YES       NO
    If yes, describe the activities.

     
     

     

     

b) Does this proposed activity involve science considered state-of-the-art?          YES      NO
  If yes, provide detail (literature citations) to support the claim.

 

 
 

c) Will this proposed activity generate new therapies or tests to achieve
or maintain a leadership role for the AHC?                                                         YES     NO

 If yes, explain what and how.

 
 

 

Outcome measure: Describe how the impact on the AHC leadership
role of the new therapy/test outcome will be evaluated. In what
timeframe? Use specific definitions and measures.

 
 
 

 

 d) Will the proposed activity results be applied in the Fairview-University
     healthcare delivery system?                                                                              YES      NO If yes, describe how and when this will occur.

 

 

 

Outcome measure: How will the application — or movement toward
application be evaluated? In what timeframe? Be specific.

 

 

 

 2.   If this EDUCATION activity is funded:
a) Will the proposed activity improve the education of health care
         professionals?                                                                                    YES     NO

    If yes, describe how.

     
     

     

    Outcome measure: How will the improvement be evaluated? Be
    specific about the measurement of meeting objectives.

     

     

     
    b) Will this proposed activity help meet an educational need not currently
        being met?                                                                                                YES     NO

    If yes, describe the need and how this activity will meet it.

     
     

    Outcome measure: How will the met need be measured?
    Be specific.

     

     
     

     
    c) Will the proposed activity apply education in the Fairview-
         University healthcare delivery system?                                                     YES     NO

    If yes, describe how this will occur.

     
     

     

    Outcome measure: How will application of the
    proposed education activity be evaluated? Be specific.

     
     

     

3.  If this CLINICAL activity is funded: CLEARLY DEFINE THE PROBLEM AND THE PROPOSED INTERVENTION:

 
 

 
a) Will this proposed activity improve a clinical — or clinical process —
outcome?                                                                                                          YES     NO

If yes, describe how. What is expected to change as a result
of intervention? Include clearly defined medical endpoints,
if appropriate.

 
 

 

Outcome measure: How will improvement be evaluated? Provide
clearly described improvements and measurable clinical outcomes.

   

b) Can the proposed activity be described as meeting the test(s) of:
    1)high social value YES/NO                 2)challenging disease state YES/NO
    3)large patient population YES/NO      4)addressing cost issues YES/NO

    For each "YES", explain how the proposed activity meets the test.

     
     

    Outcome measure: For each "YES", describe how the proposed
    activity will be evaluated in meeting each test. Be specific.

     
     

     
     

     c) Will the proposed activity attract new patients to academic physicians?      YES   NO

    If yes, describe how.

     

     

    Outcome measure: How will this be evaluated? Be specific.

     
     

     

     d) What is the magnitude of the problem the proposed activity is designed
    to address? How is this measured?

       

     
    e) Will the proposed activity create increased clinical consistency/integration
    across the Fairview System?                                                                            YES    NO

    If yes, describe how.

     
     

     

    Outcome measure: How will the change be evaluated?

     
     

     
4.  If this OTHER activity is funded:
a) Discuss how the proposed activity is compatible with the mission(s)
    of the AHC and/or Fairview.

     

     

     
    b) How easily could competitors imitate the proposed activity?

     
     

     

     
    c) Discuss the core AHC and/or Fairview competencies that would
    support the proposed activity. State the "know-how" available
    to allow us to compete to the standard in this area.

       

     
    d) Discuss the potential loss to the AHC and/or Fairview if the proposed
    activity is not funded.

     
     

     

     
Please answer all of the remaining questions in this application regardless of the type of activity proposed.

 
5.  Is the proposed activity in an AHC Strategic Priority Area and/or Fairview Service Line? Circle all that apply.

AHC Fairview

neurosciences neurosciences and pain

cancer bone marrow transplant

oncology

cardiovascular cardiovascular

transplantation organ transplant

behavioral sciences behavioral

advanced therapies orthopedics

biomedical engineering perinatal

genetics pediatrics

immunology chronic care (diabetes, Alzheimer’s)

primary care complementary care

managed care education

care for elderly and adolescents

rural health care

population sciences (health services research/

epidemiology)

 

 

 
 

 6.   Is this proposed activity multidisciplinary?                                            YES     NO

If yes, describe your plan for meaningful cooperation/collaboration
between departments, colleges, centers to perform the proposed activity.
Include names, department names, roles and responsibilities of the players.

 

 

 

Outcome measure: How will the multidisciplinary activity be reported if the project
is carried forward?

 
 

 

 

 7.  Does the proposed activity have a relationship to other AHC programs/resource?                                            YES     NO

    If yes, provide information about the other programs/resources and
    describe their relationship to the proposed activity.

     
     

     
    a) How does the proposed activity leverage other programs/resources?

 

 

Outcome measure: How will the impact on other programs/resources be
measured and reported?
 

 

 

 8. In thinking of this proposed activity as having a life cycle or span, where is          this activity in its life? (i.e., infancy, growing, stable, mature, transitional)  
 

 
9.  How long will it take for the results of the proposed activity to become

    measurable?

     
     

     

10.  Measuring merit to consumers and the community a) Will the proposed activity make a new therapy or therapies available?           YES     NO

If yes, describe the new therapy and how it will be distinguished
from other therapies.

 
 

 

Outcome measure: How will the new therapy(ies) be evaluated?
How will improvement be measured? Be specific.

 
 

 

b) Will the proposed activity have the potential to benefit Minnesota
     business?                                                                                              YES    NO

If yes, describe which businesses and how they will benefit.

 
 

 

Outcome measure: How will the benefit be measured?

 
 

 
c) Will the proposed activity increase the visibility and enhance the image:

Of the University? YES NO

Of Fairview? YES NO

If yes to either or both, describe how.

 
 

 

Outcome measure: How will the increased visibility and enhancement of
image be measured?

   

 d) Will the proposed activity address issues of:

 Improved access Yes/No

Enhanced quality Yes/No

For items answered "yes", describe how.

 
 

 

Outcome measure: How will improved access be measured?

 
 

 

Outcome measure: How will enhanced quality be measured?

 

 

 

 e) Will the proposed activity build community partnerships?                             YES   NO

If yes, describe how.

 

 

 

Outcome measure: How will the community partnering be measured?

 

 

 11.  Marketability
    a) Will the proposed activity meet a market need?                                         YES    NO

    If yes, describe the market (size, key characteristics) and the
    attractiveness of the proposed activity to the market. Will the
    proposed activity address a compelling business or market

    demand? If yes, describe the demand and support with references.

     

     

     
    Outcome measure: How will addressing the market need and impact on demand be measured?

       
     

     

     b) Will the proposed activity enhance competitiveness and differentiate
    Fairview in the marketplace?                                                                      YES    NO

    If yes, describe how and support with references.

     
     

     

    Outcome measure: How will the enhancement of competitiveness and
    the differentiation of Fairview in the marketplace be measured?

     
     

     
    c) Is there evidence the proposed activity will have volume growth
    potential?                                                                                                      YES    NO

    If yes, describe how and support with references.

       

     

    Outcome measure: How will the volume growth be measured?

     
     

     
12. Financial Considerations
a) Will the proposed activity provide an opportunity for revenue
    increases?                                                                                                     YES    NO

    If yes, describe how and support with references.
     

     

     

    Outcome measure: How will revenue increases be measured?

     
     

     
    b) Will the proposed activity reduce significantly and sustain cost
    reductions?                                                                                                 YES    NO

    If yes, describe how and support with references.

     
     

     

    Outcome measure: How will the cost reductions and sustainability
    be measured?

     
     

     
    c) Will the proposed activity be likely to meet its return on investment
    (ROI) projection and have a high probability of success?                                 YES    NO

    Explain why or why not.

     
     

     

    Outcome measure: How will the ROI and "success" be measured?

     
     

     
13.  Impact on payers, purchasers and employers
a) Will the proposed activity be attractive to and preferred by one or more
    payers such as BCBSM, Preferred One, HPI, referral sources?                            YES    NO

    If yes, state specifics.

     

     

     

    Outcome measure: How will the impact on payers/purchasers
    be evaluated?

       

     

     
    b) Will the proposed activity be likely to positively affect relationships
    with payers — i.e. foster partner versus vendor relationships?                            YES    NO

    Explain why or why not.

     

     

    Outcome measure: How will the effect on relationships be measured?

     
     

     
    c) Will the proposed activity be likely to increase
    customer/employee/member satisfaction?                                                        YES    NO

    Explain why or why not.

     

     

    Outcome measure: How will customer/employee/member satisfaction be
    measured?

     
     

     
14.  Complete the attached resource availability and need worksheet.
 

 

Signature of Principal Applicant ____________________________________Date__________________