Staying Healthy Through Education and Prevention (STEP)

Chapter 8: Behavior Coaching

Three adults blowing bubbles


The first 2 months of the STEP program include behavior coaching sessions that are conducted in group settings during the STEP classes. The coaching is designed to assist seniors in developing behavioral strategies and skills that will help them adopt and maintain active lifestyles.


This chapter describes the STEP behavior coaching program, including when and where coaching takes place and essential coaching, communication, and leadership skills. When you finish reading this chapter, you will be able to:

  • Describe the rationale and purpose of the STEP coaching program.
  • Describe when and how coaching is conducted.
  • Understand key skills for facilitating coaching sessions and group activities.
  • Demonstrate important problem-solving skills that will help you conduct the coaching portion of the STEP program.


  • Coaching: Working with another individual to facilitate change or to meet a predetermined goal.
  • Coaching skills: Group facilitation techniques that encourage participant engagement in the coaching process.
  • Behavior coaching: A method of coaching using behavioral strategies to help participants make long-term changes.
  • Behavioral strategies: Techniques or methods that create awareness and encourage practice, goal setting, and problem solving to achieve a particular goal.
  • Social Cognitive Theory: A model that proposes that behavior is affected by environmental influences, cognitive factors, and behavioral factors.

Key Points

  • Behavior patterns (including health behavior) are acquired and maintained through a complex set of behavioral, cognitive, and environmental conditions.
  • Six behavior change strategies are stressed in the behavior training component of the STEP program.
  • Nine distinct skills are important for leading successful coaching sessions aimed at changing behavior among STEP participants.

Overview of Behavior Coaching

Behavior coaching is an approach to working with individuals or groups that incorporates behavioral strategy models into physical activity coaching to facilitate a desired change. In this case, the desired behavior is 150 minutes of exercise per week. For STEP physical activity interventions to be effective, behavioral strategies must be integrated into the program. Without the behavior strategies, participants are more likely to drop out.

Behavioral Strategies and Principles

The STEP coaching sessions are based on a social cognitive model of acquisition and maintenance of health behaviors. The social cognitive model sees positive changes in health behavior as being achieved through a set of behavioral, cognitive, and environmental modifications. A number of studies have found social cognitive intervention strategies to be effective with older adults in programs aimed at increasing physical activity.

STEP combines the social cognitive approach with other strategies so that participants can develop the skills to overcome the mental and physical challenges they will face while pursuing their physical activity goals. These strategies include consciousness raising and other cognitive approaches early in the program, and reinforcement management and other behavioral approaches in the later phase of the STEP program.

The following behavioral strategies should be part of every session:

  1. Social support. Peer support is an important element in getting and keeping participants engaged. For example, the exercise buddy system gives the participant someone to go to class with and walk with.
  2. Self-awareness. Understanding one's values, feelings, and thoughts helps identify what action or behavior to change.
  3. Goal setting. You cannot achieve or measure change until you have identified the desired outcome. Setting reasonable goals helps reinforce participation in the STEP program.
  4. Feedback. Feedback reinforces participation by helping participants evaluate their progress.
  5. Positive reinforcement. Incentives, recognition, and rewards for reaching milestones or target goals reinforce participants' exercise and their engagement.
  6. Problem solving. Identifying perceived and actual barriers and finding solutions to overcome them are critical to success and something participants will need your help with.

Timing of Coaching Sessions

It is important to start new participants in the coaching sessions as soon as they enroll in STEP. The coaching sessions will provide participants with a social support system and an accountability mechanism to keep them motivated to be active, as well as the building blocks to incorporate physical activity into their daily lives.

When you introduce the STEP program into your facility initially, your coaching sessions can take place in conjunction with the STEP strength training classes. As your program grows over months and years, you will want to offer the STEP coaching sessions separate from the physical activity class. That way, new participants can benefit from the coaching sessions and "seasoned" participants who have gone through the sessions already will not become bored or irritated with the repetition.

Coaching Skills

In addition to the structured coaching sessions, STEP program leaders can incorporate and present behavior coaching strategies during the class (e.g., during warmup or cool-down). This is a great way to reinforce the changes participants have made and will continue to make. The skills that program leaders teach during the coaching sessions are not meant to exist "in isolation." They are skills that are designed to be reinforced, revisited, and reiterated continuously among all program participants.

Leading successful coaching sessions requires nine distinct skills. These skills are:

  1. Engaging in Active Listening and Empathic Communication.
  2. Asking Open-Ended Questions.
  3. Paraphrasing.
  4. Giving and Receiving Feedback.
  5. Handling Emotions.
  6. Summarizing.
  7. Solving Problems.
  8. Leading Groups.
  9. Dealing With Challenging Behaviors.

Each of these skills is described below in further detail, and examples are provided to illustrate successful application of each skill.

Skill 1: Engaging in Active Listening and Empathic Communication

Active listening is listening in a way that lets people know they have your full attention. Nonverbal attending skills include good eye contact; a relaxed, nondefensive body posture; and an open, appropriate facial expression. Verbal attending skills include vocalizations or brief statements such as "Mm hmm," "yes," or "I see" that let your participant know you are actively listening to him or her. You can do a number of things to convey active listening during behavior coaching sessions:

  • Ensure that the STEP class is not interrupted.
  • Turn down the radio if it is on, and turn off computers and television sets to avoid competing noises.
  • Listen more than you talk in every conversation.
  • Make encouraging sounds ("Mm hmm") so that participants know you are paying attention.
  • Don't interrupt or change the subject (unless your participants have wandered and the conversation needs to be turned back to exercise).
  • Don't spend too much time talking about your experiences. Your job is to listen fully to your participants' experiences and to give personal advice sparingly. Your experiences are important and may be invaluable to your participants. Just be sure your sharing doesn't take up too much time. A good general rule: participants should talk about three-fourths of the time.

Advice on Active Listening

  • Keep good boundaries. If you only have 30 minutes allotted to coaching, stick to your timeframe. You are not being rude by interrupting your participants if they get off track or are too chatty. You can say something like, "I'm going to stop you there. I know your time is precious and I want to be sure we get a chance to discuss physical activity goals for the next week."
  • Think of the people you enjoy talking to the most. Chances are they are pretty good at listening. Free advice is cheap, but careful listening is precious.

Empathic Communication

Empathic communication is the most fundamental and vital coaching skill. Conveying empathy to the participant involves two key components: understanding and reflection. Empathic understanding, or recognition, involves accurately perceiving the private, inner feelings and experiences of participants as they experience them. You need to "walk in another person's shoes" and seek to grasp the meaning of his or her experience. Empathy also requires you to go beyond factual knowledge and to achieve moment-to-moment awareness of the participant's affective, perceptual, and cognitive worlds. Understanding alone is not enough; staff must also be able to convey that understanding back to participants.

To succeed at empathic communication:

  • Maintain eye contact and a responsive posture while a participant is talking. This assures the person that you are fully present and engaged in understanding his or her thoughts and concerns.
  • When participants finish talking, reflect their concerns back to them by paraphrasing, such as: "What I'm hearing is that when you aren't able to increase your repetitions each class you feel like a failure and that makes it hard to motivate yourself for the next class. Did I get that right?" Allow them to clarify if need be. Then validate those feelings and encourage the group to do so as well.
  • Encourage participants to be specific in expressing how they feel and why, and ask questions as needed to elicit this information. This will help them clarify and better understand their feelings and will help you and the group understand and respond in an empathic way.
  • Be specific in your responses. "That sounds upsetting" does not illustrate understanding. Instead, restate the problem and the feeling so they know they have been understood.
  • Respond to the impact of events on the participant (effects on their feelings, mental state, and behaviors) rather than to "the facts" only.
  • Respond in a voice, tone, and intensity that mirrors the participant's. If someone is concerned, let your voice and face show equal concern.
  • Avoid professional jargon and clichéd introductory phrases (e.g., "Well, we've all been there," or "Sometimes life throws you curveballs") and respond in language attuned to participants.
Skill 2: Asking Open Questions

Open questions encourage a person to talk without feeling defensive. Closed questions are the kind used by doctors ("Does this hurt?"), lawyers ("Can you identify the defendant?"), and parents ("Did you eat your vegetables?") to get specific information. While closed questions are necessary at times, they do not allow people to explore their thoughts.

  • A Closed question can be answered by "yes," "no," or one word. Example: "Did you exercise Monday?" "Did you walk or bike?"
  • A Closed question starts with "is," "do," "have," and similar words. Example: "Do you want to exercise this week?"
  • A Closed question discourages talking and shuts down conversation.
  • An Open question cannot be answered by one or two words. Example: "What is your biggest challenge around exercise?"
  • An Open question usually starts with "how" or "what." Example: "What do you do to motivate yourself to exercise?"
  • An Open question encourages the person to talk.

Open-ended questions help participants be real partners in the conversation. Open questions are phrased to help people explore and discuss indepth information. When you allow participants to speak freely and personally, they are more likely to find their own solutions.

How To Use Open Questions With STEP

  1. Beginning a conversation: "What has your week been like?"
  2. Clarifying and elaborating: "What do you mean when you say you feel stuck?" What's been going on?"
  3. Working with feelings: "How did you feel after you exercised?"
  4. Solving problems: "How can you fit a little physical activity into the week?"

Advice on Asking Open-Ended Questions

  • Avoid "why" questions. They make people feel defensive.
  • Keep open questions simple and clear.
  • Expect and encourage long answers. If someone answers briefly, follow up with, "Can you tell me more about that?"
Skill 3: Paraphrasing

Paraphrasing simplifies what someone says to just "the facts" or "the essence" without extraneous details. A good paraphrase:

  • Conveys the same meaning but usually uses different words.
  • Is brief. A paraphrase is shorter than what was originally said.
  • Is clear and concise. A paraphrase clarifies things, rather than confusing them.
  • Is tentative. You want the participant to feel comfortable about disagreeing or correcting your paraphrase if it is inaccurate.

Reasons To Paraphrase

  1. To check perceptions. A paraphrase verifies that you have accurately heard your participant. When you paraphrase what a participant has said, he or she can tell you whether you are accurate or inaccurate.
    You: "It sounds like you have trouble finding time to exercise."
    Participant: "Yes, that's right. I just can't fit it in." <OR> "Well, not really. Time is a factor, but I don't really like it that much."
  2. To encourage more indepth discussion. Often a paraphrase brings up new thoughts and feelings.
    You: "So you feel happy after you exercise."
    Participant: "Yes, and you know, I feel really proud of myself, too. I never thought I could do this, but now I feel great about myself."
  3. To show empathy. An accurate paraphrase lets your participant know that you really are listening and that you understand. Empathy is central to coaching. When people feel understood, they are more likely to open up.

Advice on Paraphrasing

  • Use paraphrase or restatement instead of repeating word for word what was said, to make a person feel heard and understood.
  • Use standard opening lines such as, "Let me see if I got that right..." "It sounds like..." "So, in other words..." End by saying, "Is that right?"
Skill 4: Giving and Receiving Feedback

Giving and receiving feedback requires courage, skill, understanding, and respect for yourself and others. Here is a framework for delivering feedback in a positive, productive fashion.

  • Focus your feedback on the person's behavior, not on the person's personality. Refer to what the person does, not to what you imagine his or her traits to be. Commenting on behavior is not as personal and allows people the opportunity to change. Commenting on people's personality or character can seem critical, judgmental, and even hurtful, especially if they disagree with what you have said.
    • Behavior (positive feedback): "It sounds like you had trouble getting out of bed this week to exercise. Is there another time of day that might fit your schedule better?"
    • Personality (negative feedback): "It sounds like you're the type of person who doesn't like to get up in the morning. Is there another time of day that might fit your schedule better?"
  • Be descriptive, not judgmental. Refer to what occurred, not to your judgments of right or wrong, good or bad. Judgments arise out of a value system. Descriptions represent neutral reporting.
  • Focus your feedback on a specific situation rather than on abstract behavior. What a person does is always related to a specific time and place. Feedback that ties behavior to a specific situation increases self-awareness.
  • Share your perceptions and feelings, not advice. By sharing perceptions and feelings, you leave people free to decide how to use the feedback in light of their own goals in a particular situation at a particular time. When you give advice, you tell other people what to do with the information and thereby take away their freedom to determine for themselves what the most appropriate course of action is for them. At some point in the conversation, participants may want your professional advice, which is only natural. The more you can problem solve WITH them and help them come to productive solutions, the more likely they will follow through.
  • Do not force feedback on people. Feedback is given to help people become more self-aware. Feedback should serve the needs of the receiver, not the giver. If people are too upset, defensive, or uninterested to understand it, do not force feedback on them.
  • Do not give people more feedback than they can understand at the time. If you overload people with feedback, it reduces the chances that they will use it.
  • Focus your feedback on actions that the person can change. Your feedback should focus on the individual, not an ideal. If participants have physical limitations, habits, or preferences that they cannot or do not want to change, work within their boundaries. Be optimistic but realistic in helping them set goals. Also, focus on changing things that are within their control, such as their own thoughts and behaviors.
Skill 5: Handling Emotions

Behavior coaching sessions should focus on thoughts and emotions related to physical activity. Unfortunately, that means you won't have a lot of time to explore deep feelings about other types of situations. But remember that helping people explore exercise-related feelings teaches them important skills to work through barriers to behavior change. Encourage them to use these same skills to work on other areas of their lives.

  • Identify the feelings by asking "feeling questions."
    • "How do you feel when you complete a physical activity session?"
    • "How do you feel when you miss a session?"
  • Paraphrase spoken feelings.
    • "So you feel exhilarated when you engage in physical activity. Is that right?"
    • "Sounds like you are disappointed when you don't exercise."
  • Acknowledge the feelings.
    • "I can understand that you feel disappointed when you don't engage in physical activity."
    • "It feels so good to be energized!"
  • Relate thoughts to feelings.
    • "I can understand that you feel guilty when you don't exercise. Can you tell me what you feel guilty about?" (Often, participants feel guilty about not exercising because they think they are disappointing you. Let them know physical activity is for their own benefit, not to please anyone else.)
  • When working with negative feelings, provide positive feedback.
    • "I know you feel disappointed, but give yourself credit for what you did do. You have a lot on your hands right now. It's great that you exercised twice this week. Perhaps things will be better next week and you can try to fit in one more session then."

Advice on Handling Emotions

  • Some participants want to talk about personal problems and feelings beyond the scope of physical activity coaching. Don't feel bad about steering the conversation back to exercise.
  • If a serious nonexercise issue comes up, offer to continue the discussion after class and talk to the participants in private about where they can seek appropriate help, support, therapy, or other resources.
Skill 6: Summarizing

A summary is several paraphrases combined and often includes a reflection of feeling. A good summary helps people see what they have done and what they plan to do in the future.

A summary:

  • Serves as a perception check. (Do I really understand what we said?)
  • Demonstrates empathy.
  • Clarifies information for you and your participant.

A summary is not just a sequential recounting of what has been said. A good summary takes what was said and puts it into a logical form. It mentions thoughts and feelings and ties them together.

Advice on Summarizing

  • It really makes a person feel heard when staff can accurately reflect back what was said during a conversation.
  • Making participants feel heard helps build trust, which will be essential as you help them motivate, problem solve, and share their experiences during behavior coaching sessions.
Skill 7: Solving Problems

Inevitably, you will come across situations in which a participant is stuck or is having trouble exercising. Your goal is to help the participant find solutions to barriers, based on strategies that have worked well in the past. Now is the time to brainstorm problem-solving strategies.

Approaches to Problem Solving

  1. Make sure you have correctly identified the problem. Use paraphrasing.
    "So you've had trouble exercising because the weather is bad?"
  2. Ask the participant what he or she has done before to cope with this barrier.
    "What has worked for you in the past when it has been raining?"
  3. If the participant does not have a solution that has worked in the past, see if he or she can come up with one now.
    "What are other activities that you could do when it is raining?"
  4. If the participant has trouble generating ideas, offer some to fuel the conversation.
    "When it rains, sometimes people go to the mall to walk."
    "Some people use stationary machines on rainy days."
    "We have a great physical activity video that you can use on rainy days. It's easy and it's fun to do."

Advice on Problem Solving

  • Without a doubt, everyone has times when it is difficult to come up with solutions to problems. Give the participant time to grapple with this challenge. Try not to rush to come up with solutions for the participant.
  • Silence on the part of the participant does not necessarily mean he or she does not have an answer. Try to be comfortable with the silence; it could mean the participant is thinking hard about the problem-solving dilemma.
Skill 8: Leading Groups

A number of important skills that are part of running effective groups are listed in the table below. During the initiation of any group, it is important to be explicit about the adoption of "rules for the group." Here, we will refer to the "group leader" and "group members."

Skill Description Aims and Desired Outcomes
Active listening Attending to verbal and nonverbal communication without judgment. To encourage trust, self-disclosure, and exploration.
Restating Repeating but with slightly different words to clarify meaning. To determine if the leader has understood correctly the member's statement.
Clarifying Grasping the essence of a message at both the feeling and the thinking levels. To arrive at a meaningful understanding of communication.
Summarizing Pulling together important elements. To avoid fragmentation and give direction to a session; and to provide continuity and meaning.
Questioning Asking open-ended questions that lead to self-exploration of the "what" and "how" of behavior. To elicit further discussion, get information, stimulate thinking, and increase clarity and focus.
Interpreting Offering possible explanations for certain behavior, feelings, and thoughts. To encourage deeper self-exploration and to provide a new perspective.
Confronting Challenging members to look at discrepancies between their words and actions or body and verbal messages; and pointing to conflicting information or messages. To encourage honest self-investigation, promote full use of potential, and bring about self-awareness of contradictions.
Reflecting feelings Communicating understanding of the content of feelings. To let members know that they are heard and understood beyond the level of words.
Supporting Providing encouragement and reinforcement. To create an atmosphere that encourages members to continue desired behaviors, to provide help when members are facing difficult struggles, and to create trust.
Empathizing Identifying with members by adopting their frame of mind. To foster trust in the relationship, communicate understanding, and encourage deeper levels of self-exploration.
Facilitating Opening up clear and direct communication within the group, helping members assume increasing responsibility for the group's direction. To promote effective communication among members and to help members reach their own goals in the group.
Initiating Promoting group participation and introducing new directions in the group. To prevent needless group floundering, redirect if the discussion strays, and increase the pace of the group process.
Setting goals Planning specific goals for the group process and helping participants define concrete and meaningful goals. To give direction to the group's activities and to help members select and clarify their goals.
Evaluating Appraising the ongoing group process and the individual and group dynamics. To promote better awareness and understanding of the group's dynamics and direction.
Giving feedback Expressing concrete and honest reactions based on observation of members' behaviors. To offer an external view of how the person appears to others and to increase the member's self-awareness.
Suggesting Offering advice and information, direction, and ideas for new behavior. To help members develop alternative courses of thinking and action.
Protecting Safeguarding members from unnecessary psychological risks in the group. To warn members of possible risks in group participation and to reduce those risks.
Disclosing oneself Revealing one's own reactions to here-and-now events in the group. To facilitate deeper levels of group interaction, create trust, and model ways of revealing oneself to others.
Modeling Demonstrating desired behavior through actions. To provide examples of desirable behavior and to inspire members to fully develop their potential.
Linking Connecting the work that members do to common themes in the group. To promote interaction between member-to-members and to encourage the development of cohesion in the group.
Blocking Intervening as a leader to stop counterproductive group behavior. To protect members and to enhance the flow of the group process.
Terminating Preparing the group to close a session or end its existence. To help members assimilate, integrate, and apply in-group learning to maintain their exercise habits on their own.
Skill 9: Dealing With Challenging Behaviors

This section provides examples of challenging coaching interactions and some suggestions on how to handle them.

Chatty Participants

Some participants can be isolated or lonely, and many times a participant is just excited or relieved to talk to a caring, concerned person. Usually, a couple of moments spent "checking in" help. Something like "How was your week?" can give your participant a moment to connect with you.

Sometimes you will find that it is very hard to keep the group focused on exercise. Participants may want to discuss spouses, jobs, health problems, the past... Anything but exercise. Your role is to keep participants focused on the objective of the session and keep the conversation from "running away" from either of you. The best way to handle a chatty person is to keep tight-but-polite boundaries.

Busy Participants

Our purpose is NOT to make people feel guilty if they don't exercise. Remind participants that physical activity is something they do for themselves, not for you. They do not disappoint or hurt you if they don't exercise. What kind of job would it be if none of your participants needed your help?

Your goal is to help participants incorporate more activity into their lives and it is okay to acknowledge that sometimes this is difficult. When you communicate your understanding in this way, participants are more likely to open up and "confess" that they can't find time for physical activity or they don't like to exercise. This opens the door for you to help them problem solve in new and effective ways. If a participant needs to stop temporarily for some reason, he or she can always rejoin.

Emotional Participants

People get emotional. It's natural. Sometimes people are disappointed in their physical activity and they turn those feelings toward you. Sometimes, people have experienced a personal loss, a family illness, or another stressor. Your job is to discuss exercise, not to be a counselor; however, you do need to discuss physical activity in a way that still acknowledges and respects the person's emotions.

Here are some helpful steps for dealing with an emotional person. These approaches depend on the person and sometimes it will be an experiment. Just be willing to try. If your intention to help comes across, people will forgive any awkwardness.

  • In a group setting, you might say, "I'm sorry you're not feeling your best right now. Will you take a little break and I'll come back to you?" Then speaking to the next person: "Now Mary, tell us about your week."
  • Another option is: "I didn't realize that. Thank you for telling me. I'll see what I can do."
  • In a one-on-one encounter, you can say, "Goodness! It sounds like you've had a rough time lately. Let's sit down and take a few long deep breaths together. It might help." Then while taking noticeable, audible, deep breaths, hold up your fingers to show, "One, Two, Three, Four, Five."
  • If it seems appropriate: "I'll say a prayer for you and your family."
  • Remember that all feedback is helpful, even though the conversation may be uncomfortable.
  • It is possible that emotions have escalated as a result of medication interactions, losing a sentimental object, missing a night's sleep, or forgetting to eat or take medications. Don't take it personally. There may be events that you aren't aware of contributing to the person's emotional state.

Ill or Injured Participants

Participants may become ill or experience an injury beyond the occasional or expected soreness and fatigue that come with starting a new physical activity plan. You are not required to know all about aches and pains, so don't hesitate to refer the participant to his or her physician. If something comes to your attention during class, use the following questions and guidelines to help you assess and handle the illness or injury appropriately.

  • It helps to ask, "Where does it hurt?" If the participant answers with "my knee, hip, or ankle," it may be an issue of improper—form how the participant is doing the exercise. It may be valuable for the entire class to pause while you observe whether the person was standing or sitting knock kneed during the exercise.
  • The next question is, "Does that joint hurt only during exercise or all the time?" The participant may have arthritis, in which case initial exercise may increase discomfort, but with repetition, pain will often decrease.
  • If the participant responds to the location of discomfort in a muscle, then you can reassure him or her that this is expected. It is a sign that the muscle has received your request to grow stronger.
  • You might ask if the discomfort is sharp or dull. Any sharp pain is a sign to stop immediately.
  • If a participant has soreness beyond 24 hours after the class, ask if the person is drinking plenty of water before noon each day. Older adults sometimes avoid drinking water because it keeps them up at night, so water needs to be drunk early in the day. Adequate hydration can help to prevent cramps.
  • If a participant is experiencing fatigue and asks for your help, you can recommend recovery periods that include long deep breaths, which send oxygen into the lungs.
  • If people arrive to class not feeling well, they might just want to be with others and they should probably not exercise. As a leader, use common sense and do your best to decide the most responsible course of action in that moment. It's okay for participants to sit down and take a break, or in this case, not to start at all. However, if they risk infecting other patients or hurting themselves or others (for example, with a fall), they should be encouraged to return to their rooms and consult a physician.

Note: If a participant reports any of the following symptoms during or after exercise, the participant should stop exercising immediately and call his or her physician:

  • Dizziness.
  • Nausea.
  • Shortness of breath.
  • Chest pain (including chest discomfort or pressure, left arm pain, or indigestion or stomach discomfort).
  • Tingling in the hands or feet.

Keys to Facilitating During Difficult Situations

  • Be nonjudgmental.
  • Be empathic.
  • Give individualized advice to help problem solve.
  • Don't ask "why" or closed-ended questions.
  • Don't take the participant's behavior personally.
  • Don't interpret (when a paraphrase will do).
  • Stick to the "here and now."
  • Stick with the topic of exercise.
  • Ask for help when you need it.
  • Give encouragement and praise for the small things.

Seek consultation immediately if a participant talks about depression, alcohol, drugs, abuse of self or another, or suicide.


Jones CJ, Rose DJ, eds. Physical activity instruction of older adults. Champaign, IL: Human Kinetics; 2005. Chapter 8: Goal setting and behavior management.

Page last reviewed October 2014
Page originally created February 2011
Internet Citation: Chapter 8: Behavior Coaching. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.