Tag Archives: HRSA

The Distinction Between Services Offered Now and Services Later, Illustrated by the HRSA Oral Health Service Expansion (OHSE) Program

When you’re writing a proposal for a grant intended to expand an existing program or service, it is extremely, ridiculously important to distinguish between what your organization is currently doing and what it’ll be doing with the new money. Failure to do so means that a) you raise the specter of supplantation, b) you sound like you don’t need the money because you’re already offering the services, and c) someone with a better grant story will get the money. Applying for a grant leads to a binary outcome—either you get the grant or you don’t. There are no half grants.

Let’s use HRSA’s Oral Health Service Expansion (OHSE) Program as an example. As the name of the program implies, OHSE is designed to provide additional dental services to underserved low-income patients.* A good OHSE proposal describes what, if anything, the applicant is currently doing with respect to oral health services (e.g., no services, pediatric only, pregnant women only, Medicaid only, etc.), and then describes what will be done differently. The applicant should say what additional services will be offered (e.g., sealants for children, dentures, etc.), and show how the dental patient population will be expanded. The applicant might serve additional existing FQHC medical patients, other service area residents, left-handed one-eyed cyclops, and so on.

A reasonable expansion might be as simple as saying, “The Toppenish Community Health Center currently serves 2,000 patients with 4,000 dental visits annually. The OHSE grant will allow TCHC to serve 3,000 high-risk patients, including at least ten cyclops.” What the organization can’t do, however, is claim that the CHC already serves 2,000 patients, and the grant will allow the CHC to keep serving those patients with more or less the same services. Patients have to be served in either greater number or greater services, or both.

Many  FQHCs that seek OHSE grants will also have long waiting lists, which can be used to bolster need: If the current waiting list for a new dental appointment is six months, that indicates a severe shortage of oral health service capacity. It doesn’t held your proposal to say proudly that the CHC’s wait time for a new dental patient is two days.

In short, applicants shouldn’t ever write or imply that they won’t actually serve more patients, or a larger area, or provide additional services. This may seem obvious, but we’ve seen proposals written by others that fail to remember this rule and that are primarily boasts about how much they’re already doing. That flaw won’t always be fatal—the funder may just want to fund that particular applicant or that particular service area—but it should still be avoided.

* Fun fact: Some dentists prefer the term “oral cavity” rather than “mouth.” I’m not sure why, since to me the former term sounds vaguely pornographic, and the latter term sounds normal.

HRSA Randomizes FQHC Program Officers, Likely Trading One Set of Problems for Another Set of Problems

In days of yore, most federal grantees had a dedicated program officer who handled budget issues, contract amendments, reports, and the like; the program officer would often conduct site visits, getting to know the executive director and the nuances of the agency and target area. This system began to atrophy during the Reagan administration with cutbacks to federal travel budgets, and today grantees rarely if ever see their program officer. For example, we’ve written many funded YouthBuild proposals for a South Central LA nonprofit, which hasn’t had a site visit from their HUD program office in 20 years of implementing over ten rounds of YouthBuild funding. Still, most grantees develop a virtual relationship with a specific program officer.

We write many HRSA proposals and were surprised to learn during a scoping call with the CEO of a long-time FQHC client that HRSA has changed this system. Instead of having an assigned program officer, HRSA program officers are now randomized. This means that when an FQHC—which often juggles multiple HRSA grants—has an issue, the problem is randomly assigned to one of a pool of program officers. This is more or less the system used when one waits in line at the DMV or Katz’s Delicatessen. At the DMV, this prevents a clerk from issuing fake drivers licenses for a bribe and the counter man at Katz’s from adding a little extra corned beef to his pal’s sandwich every day at lunchtime.

I assume the same reasoning applies at HRSA: randomizing program officers presumably is aimed at preventing special treatment for favored FQHCs or, I suppose, outright graft. Avoiding special treatment has a cost, though, as it’s likely to wildly increase inefficiency and systemic friction. One sees such problems most clearly in defense contracting, but any large bureaucracy can develop them.

In a randomized oversight management system, the program officer handling a particularly issue will have no agency background or context for the problem. I’m sure that HRSA management thinks thinks will lead to “fair” treatment for all grantees, while minimizing the potential for corruption, but it will also clog the system. HRSA program officers are probably GS 11s and 12s and, like most bureaucrats, they aren’t especially motivated to quickly solve grantee problems. Relationships with the grantees can improve motivation because most of us don’t want to be considered jerks by people we know and have repeated interactions with (why this is true is beyond the scope of this post, but Joseph Henrich’s account in The Secret of Our Success is recommended; it’s also a popular book written by a scholar, not a self-help book). Program officers get paid every two weeks, whether they solve problems or create them, as long as their breath clouds a mirror (to prove they’re still alive) when the paychecks are passed out.

HRSA is changing one set of real or imagined problems for a different set of problems. An unintended consequence of this change is also likely to be more congressional interference.

Why? Let’s say you’re the CEO of the fictional Owatonna Community Health Center and need a rapid decision to amend the agency’s NAP grant budget. In the Ancien Régime, the experienced program officer could probably be sweet-talked into a quick budget revision because of the interpersonal relationship and agency knowledge. In the new system, however, the program officer might put the request under her coffee cup and leave for five days of training, followed by vacation. Why does she care about what some random FQHC in Minnesota or wherever thinks or does?

Without any other recourse, the panicked CEO is likely to call their congressperson’s district office for relief, which will result in a field deputy harassing upper level HRSA management in Washington. This will lead to more friction and bad vibes, as management puts the congressionally-induced hammer to the program officer. The program officers will become even more bureaucratic in response, and they’ll make sure every last rule gets followed. Meticulously following rules is actually a CIA-approved method for organizational sabotage. No, seriously, it is: follow the preceding link.

We’ve written about the challenges of managing grants before. Like grant writing, grants management involves a specific set of skills and experience. Anything that makes managing grants harder is not going to help HRSA or FQHCs in the long run.

Thought of the Day: Funders Could Provide Proposal Templates in Word

Federal, state, local and foundation funders could save everyone, including themselves, a lot of grief and heartache by including a Word proposal narrative template with every RFP.

Let me explain: this may not be the most compelling way to start a post, but if you don’t like to waste your time, energy, and precious life on this planet you’ll stay with me even when I write about how last week I was formatting a particularly tedious HRSA proposal. This proposal’s narrative instructions alone have more than ten pages of headers, sub-headers, sub-sub-headers, inconsistent number/bullet patterns, and instructions. I followed the model Isaac wrote about in “What Does a Grant Proposal Look Like Exactly? 13 Easy Steps to Formatting a Winning Proposal:”

Learn to love outlines. If the RFP has an outline format, reproduce it. If not, develop a simple outline format of your own, indenting .2 or .25 inches as the outline descends. It is easy to do this in Word by using paragraph styles. Make Outline 1 “A” with no indent, Outline 2, “1″ with a .2 indent, Outline 3 “a” with .4 indent and so forth.

Not surprisingly, I succeeded in creating an attractive outline.* But I also spent many hours creating styles, copying and/or rewriting header text, and deciding on the formatting necessary to reproduce this relentlessly, tediously verbose HRSA RFP. Towards the end of the process I realized: HRSA didn’t have to make me do all this! HRSA doesn’t have to make each applicant use subtly different sub-heading text, as is currently the case. They could offer an optional proposal template in Word that already has all the narrative headers in a style that’ll make proposals easier for HRSA to read and easier for applicants to write. Everyone wins!

Standardized proposal templates would be slightly bad for our business, because plenty of people see the byzantine narrative structure, become distressed, and think hard about how quickly they can pay someone else to make the pain go away. But they’d be a net win for humanity, and, at heart, I am a humanitarian. Think about it, funders: a tiny amount of work on your end could be a great virtue for all mankind.

* Don’t underestimate the value of instant attraction in just about any domain. Publishers spend a lot of time and money getting book formatting right for a reasons. They know that readers judge a book based not only on the particular words used but on the way those words are shaped and presented. We’ve seen many, many clients who turn in sloppily formatted proposals or who sacrifice readability for more words. Those are mistakes.

The HRSA Health Infrastructure Investment Program (HIIP) Illustrates Why It’s Hard to Handicap Chances of Getting a Grant

Anyone who’s been to a race track or Vegas knows that the odds of a given race or sporting event are being constantly updated by pros who seem to know how to handicap future events. Prospective clients often ask me to handicap their chances of winning a grant competition (and we’ve written before about why grant writing is not like the Olympics). Trying to handicap a particular grant competition is like trying to handicap a horse race in which you don’t know the horses, riders, or venue until after the race is completed. If grant writing was really like a horse race, you’d just pick the cutest horse or jockey with the best colors and hope for the best.*

A prospective client raised the odds issue on Friday, regarding the recently issued Health Resources and Services Administration (HRSA) Health Infrastructure Investment Program (HIIP) FOA. HIIP has $150,000,000 available, with about 175 grants up to $1,000,000, for Federally Qualified Health Centers (FQHCs). FQHCs are sometimes called “Section 330 grantees” and provide primary health care to publicly (Medicaid) and uninsured patients. HIIP is a great opportunity for FQHCs: there’s a lot of money up for grabs, the grants are large, and the money is for facility improvements (facility improvements are always hard to fund).

Not surprisingly, we’ve received a number of inquiries from FQHCs. On Friday, a FQHC CEO in rural Montana called. I learned a bit about his agency and provided a fee quote. Then he popped the question: “So, what are my chances of being funded?” As I was starting my standard reply to this standard question, he interrupted. He said he didn’t think his chances were very good, because “thousands of FQHCs would apply.”

I said that’s not true, since there aren’t that many FQHCs. We got into a bit of a tiff over this, so I double checked after the call. The Henry J. Kaiser Family Foundation says there were only 1,202 FQHCs as of 2013. I would’ve guessed closer to 1,000, but the numbers are in the same ballpark. While new FQHCs are created every year, there are likely less than 1,300 today. Thousands of FQHCs can’t apply for HIIP because not that many exist. My caller was trying to talk himself out of applying.

Let’s try estimating the likely competition.

For various reasons, not every FQHC will want to apply for a HIIP grant. Some are already happy with their current facilities, while others are undergoing leadership changes. Let’s assume that 1,000 FQHCs want to apply and that HRSA will ultimately make about 175 grants. This would mean around a 20% chance of any given application being funded, which is pretty good odds in submitting a grant proposal or buying a lotto ticket.

But, of the hypothetical 1,000 or so applicants, many will not finish their applications, so perhaps 700 applications will actually be submitted. Of these, a fair number, say 100, will be technically incorrect and will not even be scored. Now the pool is down to 600. Many of these will be poorly written, fail to demonstrate need, etc., and will not score high enough to be funded. Let’s assume that 350 – 400 score high enough to be funded.

Now the odds are close to one in two!

Still, grant handicapping is more complex than this simple analysis. Of my theoretical 400 potential grantees, some will be urban, some rural, some will serve special populations (e.g., homeless, Native Americans, etc.). Some will serve African Americans, some Hispanics and so on. Since, like all governmental funders, HRSA is a semi-political entity, the organization wants to spread the sugar. Even if the top 200 applications, based on points alone, were somehow clustered in the Northeast, applicants in other areas would still be funded.

My 400 possible grantees are actually competing against similar applicants, rather than all applicants, because not all applicants are equal in the eyes of HRSA administrators. If your FQHC is the only highly scored applicant that serves rural Native Americans, your chances of being funded could be 100%. If your FQHC serves a general population in a large city like New York or LA, you might be one of ten possible grantees in that city. HRSA will likely make multiple awards in a given big city, but not ten. Now your odds could be one in three. This particular exercise can be played ad infinitum, but it doesn’t mean much because no one outside of HRSA knows the organization’s subjective priorities in advance and because you don’t know who else is going to apply.

Not knowing who else is going to apply really counts. If four other FQHCs similar to yours operate in a given region, they may all say they’re going to apply—just to scare you, or intimidate you, or impress you, or for any number of other reasons. Will they? Maybe, maybe not. You can’t control them, and we recommend that you not be dissuaded by their rhetoric. They may claim to have juice with power players in Washington, or any number of other advantages. You don’t know and can’t know if they’re telling the truth.

My advice to all callers is the same: if your agency is eligible and you want to provide the service, you should disregard real or imagined odds and apply. The logic is similar to seeking a new job. In most cases, you don’t know the other job applicants. Most people apply for jobs they want to do in places they want to live. Say you’re a highly qualified lion tamer and there is a great job open at a circus in Seattle. You should only apply if you like rain, coffee, and tech / nerd culture. If you like sunshine, Cubano sandwiches, and salsa dancing instead, wait for a circus opening in Miami.

The same is true for HIIP: FQHCs who need facility improvements should complete technically correct and compelling proposals that are submitted on time. Worrying about the odds is an interesting but pointless enterprise.

* This is actually the way I bet at horse races, which is why I’m not much of a gambling man.

One Way You Know a Grant Maximum is Too Low: HRSA and “‘Now is the Time’ Project AWARE-Community”

In 2014 HRSA released a program melodiously called “‘Now is the Time’ Project AWARE-Community,” and the program had almost 100 awards available for an eight-figure pot of money—but the individual maximum grant was only $50,000. Last week, HRSA released the same RFP, but with different funding parameters: 70 awards are available with a maximum grant size of $125,000—or 150% more than last year’s award.

We’re guessing that the maximum award changed because $50,000 was just too little money to get most organizations interested in the program, which is designed “to train teachers and other school personnel to detect and respond to mental illness.” Fifty thousand dollars, once overhead and administration is accounted for, won’t even yield a full-time trainer. The current maximum grant, $125,000, will. The program just got a lot more compelling for both nonprofits and school districts. HRSA is also signaling to applicants that they know the last funding round didn’t offer large enough grants to be interesting.

Grant Writing Confidential Goes to the Movies Part 3: Ghostbusters (Who Ya Gonna Call? Program Officers!)

Ghostbusters was Jake’s favorite movie when he was a child. He watched the video at least a hundred times and it remains a classic of its type.* As Ray Parker put it in his incredibly catchy, eponymous Ghostbusters theme song, “When there’s something strange in the neighborhood, who ya gonna call? Ghostbusters!” There’s a Koanic simplicity in this advice: when you have a problem, call the expert, not someone pretending to be the expert.

I was reminded of this over the summer, because we wrote proposals for clients applying to several federal grant programs with incredibly complex RFPs and underlying guidelines, including the HRSA New Access Point (NAP) and the Early Head Start (EHS) programs. Our clients for these assignments all had unusual or complex project concepts that required closely reading and carefully interpreting the RFPs and regs. The RFPs and regs raised issues for both our clients, though we can’t specify what those issues are; trust us when we say that they were real.

Our standard advice to clients in this situation—and as we’ve we’ve written about many times—is to immediately contact the Program Officer listed in the RFP and pop any questions about vague descriptions or apparent conflicts. At Seliger + Associates, we almost never contact Program Officers directly, since they rarely pay attention to consultants. Instead, we coach our clients on how to pose the question and get as clear a written interpretation as possible.

But our NAP and EHS clients didn’t want to contact the Program Officers; instead, they sought guidance from their state association, which are effectively trade groups for grantees. For large programs, like HRSA Section 330 and Head Start, networks of state and national organizations have grown up, which provide technical assistance and the ever-popular grantee conferences. An example is the Community Health Care Association of New York State, which is composed of Section 330 providers in New York and assorted hangers-on (note that we did not write a NAP proposal in New york this year—and I found CHSNYS through a Google search). When a big RFP for NAP, Head Start and similar federal programs comes along, these associations put on a full-court press to “help” applicants in their states prepare proposals. This help does not mean writing the proposal, although sometimes the association will provide data and research citations. The technical assistance usually involves meetings, Powerpoint presentations, webinars and so on.

Applicants rarely realize, however, that their association provides the same help to all agencies in their state. Rather than being truly interested in their particular agency submitting a technically correct proposal, the association is more like a mom passing out orange slices at a middle school swim meet—they want all agencies to come in first. Like a swim meet, however, and human nature being what it is, some applicants are favored by the “moms” and get extra orange slices, while others get orange-dyed onion slices.

We had a NAP client a few years ago in a western state that ran into active opposition from the state association because the association staff hated our client. I know this for a fact, because the association Executive Director told me so! Despite the association’s animus and refusal to provide a support letter, we wrote a compelling proposal, which was funded, much to the annoyance of the association, which then had to include our client.

The basic problem in asking associations or consultants for RRP interpretation is simple: they don’t work for the federal agency. Their opinions regarding a particular RFP don’t mean anything. The only way to get an interpretation of an RFP is by asking the Program Officer in writing and getting a written reply. Even then, the response is likely to say something like “this is subject to the guidelines, as published in the Federal Register.” Over the years, we’ve helped our clients thread their way through this process many times, including instances in which the federal agency published a correction to the RFP (as Jake writes at the link). A published RFP amendment is the gold standard for RFP interpretation.

Be careful in taking the advice of your state association, no matter how much fun their conferences are. When there’s something strange in a RFP neighborhood, who ya gonna call? Program Officers!

* I recently saw the grandaddy of ghost/comic films, 1940’s The Ghost Breakers, with the hilarious Bob Hope, exquisitely beautiful Paulette Goddard and a very young Anthony Quinn. If you like Ghostbusters, you’ll love The Ghost Breakers. It’s little non-PC, but the movie was made in 1940.

“You Can’t Shovel Tens Pounds of Shit in a Five Pound Bag:” The New York Times Ignores CHCs, Section 330 Providers, and HRSA

In “For Many New Medicaid Enrollees, Care Is Hard to Find, Report Says,” Robert Pear discovers something that has long been obvious to our many Community Health Clinic (CHC) clients: having insurance doesn’t mean you can see a doctor. Many if not most doctors won’t see Medicaid patients. CHCs, however, are a class of primary care organization designed specifically for Medicaid patients and the uninsured. We’ve written numerous Health Resources and Services Administration (HRSA) proposals for CHCs, and everyone one of those proposals is supposed to expand access to care. This year’s New Access Point (NAP) program, for example, has $100 million available. Pear apparently does not know that CHCs exist and are funded through HRSA mostly to serve Medicaid patients.

The bigger problem regarding real-world healthcare is the number of doctors. Any discussion about the difficulty of finding care that doesn’t mention the limits on the supply of doctors is specious at best. There have been around 100,000 residency slots since the 1980s. Medical schools stopped expanding long ago. These facts are well-known to experts. Physician Assistants and Nurse Practitioners are to some extent filling in the gap, but in most states they still must practice under a doctor.

Our CHC clients’ biggest problem is rarely recruiting patients—when you subsidize goods or services, people consume more—it’s finding doctors. CHCs usually serve a high-need, difficult-to-treat population. Consequently, physicians often prefer to seek higher pay and lower stress jobs. Although there are lots of people trying to go to medical school—in Educating Physicians: A Call for Reform of Medical School and Residency, the authors note that 42,000 people applied for 18,000 medical school spots, and that at least 30,000 were likely qualified to become doctors—med school and residency act as bottlenecks to this process.

You can give every person health insurance without ensuring that they’ll actually get care, much like you can give everyone a degree without ensuring they have a brain. In the United Kingdom, care gets rationed through wait times. In the U.S., a similar dynamic is happening via provider shortages. While it is laudable that the Affordable Care Act (ACA) significantly increased the number of Americans covered by Medicaid, the landmark legislation did little to increase the number of providers to serve the newly insured. Or, as they used to say in the old days, you can’t shovel ten pounds of shit into a five pound bag. It’s a vulgar phrase but applicable to this article and the overall challenge of helping the newly insured actually access affordable, quality healthcare.

Many Proposals Are Swimming Against the Tide: An Example From HRSA’s New Access Point (NAP) FOA

Take a look at the laundry list of stuff that HRSA wants New Access Point (NAP) applicants to somehow improve (the quote comes from page 38 of the 101-page FOA):

Diabetes, Cardiovascular Disease, Cancer, Prenatal Health, Perinatal Health, Child Health, Weight Assessment and Counseling for Children and Adolescents, Adult Weight Screening and Follow-Up, Tobacco Use Screening and Cessation, Asthma – Pharmacological Therapy, Coronary Artery Disease (CAD) – Lipid Therapy, Ischemic Vascular Disease (IVD) – Aspirin Therapy, Colorectal Cancer Screening, New HIV Cases With Timely Follow Up, Depression Screening and Follow Up, and Oral Health.

Improving almost all of those metrics really starts with behavior, not with care. The real way to better health can be reduced to a couple things: 1. Eat better. 2. Get some exercise.* 3. Avoid the obvious drugs. 4. Brush and floss.

But those things have been public health goals for the last 50 years, and in the meantime Americans have gotten fatter and by most metrics less healthy—except, curiously, for longevity. We’ve built cities and suburbs that are actively unhealthy because they force everyone to drive everywhere all the time. Smoking rates have fallen, but they’re still stubbornly high and have been hovering between 20 and 25% for years. Cancer and heart disease look like eternal public enemies who can no more defeated than drug traffickers or superheroes.

Changes can’t and thus aren’t going to come from a bunch of doctors and nurses telling their patients—yet again—to lay off the McDonald’s and the soda and instead hit the gym for squats. HRSA knows this to some extent, and whoever sees the evaluations for NAPs in a couple years is going to know that opening one new primary care health clinics is equivalent to chucking a pebble in the river of behavior and culture. It is true that the federal government also subsidizes big agriculture in various ways that make eating well relatively harder and more expensive than it should otherwise be, but a lot more people could swim against that tide than actually do.

People who get and stay in shape do so because they realize it makes them feel better and because it dramatically increases their mating market value. Until they get sick and tired of being sick and tired—or, rather, until they get sick and tired of being the butt of jokes—no one is going to make them change. Pressure from external sources, like doctors, rarely does it. Treatment will never be as effective as prevention, but prevention can’t be mandated from above. It has to emerge from below. It would be interesting to see a study of the health behaviors of HRSA bureaucrats compared to the general population and a population of their peers.

The other night I was hanging out with a bunch of doctors and almost all of them were smoking cigarettes outside a bar. These are doctors. No one knows more about how dangerous smoking is. But they wanted drinks to take the edge off and for the usual reasons having a cigarette or three helped the relaxation process. I’m not even going to start into the unprotected sex stories—commonly referred to as “raw dogging” among today’s urban 20- and 30-somethings. As usual the stories may be exaggerated, but some episodes may also not bubble up into even impolite conversation.

(By the way, these same doctors like to note how infrequently patients take their standard advice: stop smoking, drink less, lose 20 pounds. To them medicine often feels like a futile endeavor.)

We’ve noticed one other thing, which isn’t related to the main point of this post but is likely to be hilarious to the right audience. CHCs—sometimes called Section 330 providers—must have community-based Board of Directors. At least 51% of these Boards must be composed of “consumers,” and the board is supposed to “Approve the selection/dismissal and conducts the performance evaluation of the organization’s Executive Director/CEO.” HRSA requires that NAP applicants say as much, and say that the Board has control over the Executive Director. This is saying the applicant will certify that the sun rises in the East.

The bylaws of every nonprofit typically state that the executive director/CEO serves at the pleasure of the board. Who else would hire, evaluate and, if necessary, fire the CEO? While some CHC CEOs can come from the clinical side, like a physician, they are often a health administrator type or general purpose nonprofit manager. More importantly, they are often the founder and/or prime mover in the organization.

Let me repeat that: they are the driving force behind the organization. That isn’t true in the largest organizations, but in small ones the Executive Director usually controls the board, no matter what the bylaws nominally say, because taking away the key person who built the organization usually kills the organization. It’s like “firing” the donor keeping the organization alive. It rarely happens in small- or medium-sized organizations. Nonetheless, in the proposal world the patients represented on the board have all the power. Among most actual NAP applicants, the real power isn’t likely to reside in the non-experts who can be rounded up to sit on the Board.

* I’ve become a much more regular lifter since reading “Everything You Know About Fitness Is a Lie,” and to a lesser extent Starting Strength and Arnold: The Education of a Bodybuilder. The last one is admittedly not very good yet I like it anyway.

What Happens If You Have a Party and No Girls Show Up? HRSA’s Healthy Start Initiative (HSI) FOA Tries Again

We just finished working on proposals for HRSA’s Healthy Start Initiative (HSI); we’ve written funded HSIs before, so we’re very familiar with the program. HSI, however, just reappeared as a Valentine’s Day Present, with a new deadline of March 31 and almost $40 million available. That link goes to the RFP.

What gives?

The RFP answers:

The number of applications received. . . was much less than expected. As a result, HRSA anticipates that funds will be available to support additional applicants after completing reviews and funding decisions of applications submitted for [HSI].

HRSA didn’t get enough applications—they threw a party and no girls showed up, which is strange because HRSA is trying to give away money. We can speculate on why HRSA didn’t get enough applications, or technically correct applications, starting with: The RFP was difficult. We worked on HSI over the holidays; a lot of people probably gave up and went back to the celebrations, or turned in technically incorrect proposals.

In honor of HRSA and drinking over the holidays, we’ll offer a 10% discount to anyone who wants to apply for HSI this time around. Call us at 800.540.8906 for a free quote.

We know that programs have been re-released one after another before, though we can’t think of any examples right now. Those other ones must have taken place before we started the blog, because we can’t find any posts on this particular topic. Chalk it up to the inherent weirdness of Federal grant making. As Winston Churchill is said to have said of the Russians, “It is a a riddle wrapped in a mystery inside an enigma.”

The Narrative Should Use the Headers the Funder Says It Should Use: HRSA’s Health Start Initiative (HSI)

A few days ago I was describing some of the weirder sections in HRSA’s Healthy Start Initiative: Eliminating Disparities in Perinatal Health (HSI) program to my fiancée, and between the time I started and the time she fell asleep I mentioned that a proposal’s disjointedness often comes not from the writer but from the RFP. Proposals aren’t written for humans; they’re written for bureaucrats. That’s true for most federal proposals, some state proposals, fewer local proposals, and least of all for reasonably unstructured foundation proposals.

Way back in 2012 we wrote “Upward Bound means more narrative confusion,” which described how that RFP “practically hide[s] the location of the material you’re supposed to respond to.” Today I’d like to talk about an exciting, sexy, related topic: HSI (which is due tomorrow). Like Upward Bound, it has two logical places that a moderately intelligent writer could use to structure the narrative: the first is on page 22 of the RFP, which says things like: “INTRODUCTION — Corresponds to Section V’s Review Criterion 1.”

Notice the language used: “Corresponds to Section V’s Review Criterion 1.” Review Criterion 1 starts on page 43, and it has very clear section headers that could be used to structure a fairly clean and clear proposal. I was tempted to use them and I bet a lot of other people have used them in the past, since HRSA put a simple but easily missed instruction on page 22: “Use the following section headers for the Narrative.”

That instruction should be and is the end of the debate. Because of it, anyone who uses the page 43 Review Criteria is doing it wrong. As always with grant writing, it may be possible to do it wrong and then get funded anyway, but you should always err on the side of obeying the RFP.

As you might imagine, we’ve had some… discussions… around this issue with clients. I’ll leave the nature of those discussions intentionally euphemistic, but in the meantime I will note that they should not have been as long or contentious as they were.

HRSA proposals are particularly finicky with narrative starts. The Nursing Workforce Diversity (NWD) Program, for example, has the same weird, bifurcated structure, in which the narrative beings on page 10 and the review criteria on page 21. It isn’t as monstrous as HSI—the final submission package is 65 pages max, as opposed to HSI’s 100 pages, and the RFP is correspondingly shorter—but it does the same confusing thing.

From a writer’s perspective, the (imperfect) solution is to write with the mandated narrative headers and then make sure that the response hits all the review criteria. If it doesn’t, pick up some of the language from the response and then use that as a jumping off section for a paragraph. For example, HSI has a review criterion that starts, “The extent to which the proposed quality improvement plan describes an ongoing/continuous overall management approach…” and you should answer it by saying, “The proposed project will implement a quality improvement plan describes an ongoing/continuous overall management approach by creating a database that will be used by CHWs to…”

That’s a nice thing to do for the reviewers, because it allows them to check the box and ideally give you the maximum number of points possible. It would be even smarter to make the narrative instructions and review criteria identical, but HRSA evidently isn’t yet that evolved—which makes our job harder. But if we wanted an easy job, we would have become lion tamers.