Centers for Disease Control and Prevention
Agency Leadership Taking Steps to Improve Management and Planning, but Challenges Remain Gao ID: GAO-04-219 January 30, 2004The scope of work at the Centers for Disease Control and Prevention (CDC) has evolved since 1946 from a focus on communicable diseases, like malaria, to a wide and complex range of public health responsibilities. The agency's Office of the Director (OD) faces considerable management challenges to ensure that during public health crises the agency's nonemergency but important public health work continues apace. In 2002, the agency's OD began taking steps aimed at organizational change. GAO has observed elsewhere that major change management initiatives can take at least 5 to 7 years. In this report, GAO examined the extent to which organizational changes have helped balance OD's oversight of CDC's emergent and ongoing public health responsibilities. Specifically, GAO examined OD's (1) executive management structure, (2) approach to overseeing the agency's work, and (3) approach to setting the agency's priorities.
The management team in CDC's top office--OD--is undergoing a structural change designed to provide a new approach to managing the agency's public health work. Through this effort, CDC has taken steps that have merit. For example, OD established a Chief Operating Officer position with clear oversight authority for the agency's operations units, such as financial management and information technology. However, a significant oversight weakness remains: there is no position or combination of positions on OD's management team below the Director's level to oversee the programs and activities of 11 centers that perform the bulk of the agency's public health work. Only CDC's Director has line authority for the centers, and the extraordinary demands on the Director's time associated with public health emergencies and other external events make the practicality of this oversight arrangement uncertain. Another of OD's structural initiatives was to align OD management team positions with broad mission "themes," or goals, that cut across the centers' institutional boundaries. The intent was to foster among the 11 independent centers a more integrated approach to performing the agency's mission. This purpose may be difficult to realize, however, as connections between certain themes and associated OD positions are not sufficiently clear. OD has made improvements in its ability to oversee the agency's response to public health emergencies--including the creation of an emergency preparedness and response office and the development of an emergency communication system--but concerns remain about OD's oversight of nonemergency public health work. OD's efforts to monitor the activities of the centers are not sufficiently systematic. For example, few formal systems are in place to track the status of centers' operations and programmatic activities. Although OD has a process for center officials to elevate important issues of concern, the information flow under this process is largely center-driven, as the subjects discussed are typically raised at the discretion of the center officials. Similarly, OD's efforts to foster coordination among the centers fall short of institutionalizing collaboration as standard agency practice. The planning tools that OD needs to set agency priorities and address human capital challenges are under development. In recent years, OD has operated without an up-to-date agencywide planning strategy with which to set mission priorities and unify the work of CDC's various centers. In June 2003, OD initiated an agencywide strategic planning process. In a separate planning effort initiated in April 2003, CDC began working on a human capital plan for meeting the agency's current and future staffing needs. This effort has been suspended while the strategic planning process gets under way, and no time frames have been established for resuming its development. At the same time, agency attrition and future limits on workforce growth suggest that agency leadership may be needed to ensure that workforce planning occurs expeditiously.
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Director: Team: Phone:GAO-04-219, Centers for Disease Control and Prevention: Agency Leadership Taking Steps to Improve Management and Planning, but Challenges Remain
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Report to the Director of the Centers for Disease Control and
Prevention:
United States General Accounting Office:
GAO:
January 2004:
Centers for Disease Control and Prevention:
Agency Leadership Taking Steps to Improve Management and Planning, but
Challenges Remain:
GAO-04-219:
GAO Highlights:
Highlights of GAO-04-219, a report to the Director of the Centers for
Disease Control and Prevention
Why GAO Did This Study:
The scope of work at the Centers for Disease Control and Prevention
(CDC) has evolved since 1946 from a focus on communicable diseases,
like malaria, to a wide and complex range of public health
responsibilities. The agency‘s Office of the Director (OD) faces
considerable management challenges to ensure that during public health
crises the agency‘s nonemergency but important public health work
continues apace. In 2002, the agency‘s OD began taking steps aimed at
organizational change. GAO has observed elsewhere that major change
management initiatives can take at least 5 to 7 years. In this report,
GAO examined the extent to which organizational changes have helped
balance OD‘s oversight of CDC‘s emergent and ongoing public health
responsibilities. Specifically, GAO examined OD‘s (1) executive
management structure, (2) approach to overseeing the agency‘s work,
and (3) approach to setting the agency‘s priorities.
What GAO Found:
The management team in CDC‘s top office”OD”is undergoing a structural
change designed to provide a new approach to managing the agency‘s
public health work. Through this effort, CDC has taken steps that have
merit. For example, OD established a Chief Operating Officer position
with clear oversight authority for the agency‘s operations units, such
as financial management and information technology. However, a
significant oversight weakness remains: there is no position or
combination of positions on OD‘s management team below the Director‘s
level to oversee the programs and activities of 11 centers that
perform the bulk of the agency‘s public health work. Only CDC‘s
Director has line authority for the centers, and the extraordinary
demands on the Director‘s time associated with public health
emergencies and other external events make the practicality of this
oversight arrangement uncertain. Another of OD‘s structural
initiatives was to align OD management team positions with broad
mission ’themes,“ or goals, that cut across the centers‘ institutional
boundaries. The intent was to foster among the 11 independent centers
a more integrated approach to performing the agency‘s mission. This
purpose may be difficult to realize, however, as connections between
certain themes and associated OD positions are not sufficiently clear.
OD has made improvements in its ability to oversee the agency‘s
response to public health emergencies”including the creation of an
emergency preparedness and response office and the development of an
emergency communication system”but concerns remain about OD‘s
oversight of nonemergency public health work. OD‘s efforts to monitor
the activities of the centers are not sufficiently systematic. For
example, few formal systems are in place to track the status of
centers‘ operations and programmatic activities. Although OD has a
process for center officials to elevate important issues of concern,
the information flow under this process is largely center-driven, as
the subjects discussed are typically raised at the discretion of the
center officials. Similarly, OD‘s efforts to foster coordination among
the centers fall short of institutionalizing collaboration as standard
agency practice.
The planning tools that OD needs to set agency priorities and address
human capital challenges are under development. In recent years, OD
has operated without an up-to-date agencywide planning strategy with
which to set mission priorities and unify the work of CDC‘s various
centers. In June 2003, OD initiated an agencywide strategic planning
process. In a separate planning effort initiated in April 2003, CDC
began working on a human capital plan for meeting the agency‘s current
and future staffing needs. This effort has been suspended while the
strategic planning process gets under way, and no time frames have
been established for resuming its development. At the same time,
agency attrition and future limits on workforce growth suggest that
agency leadership may be needed to ensure that workforce planning
occurs expeditiously.
What GAO Recommends:
GAO recommends that the CDC Director ensure OD‘s oversight of the
centers‘ programmatic work at a level below the Director, improve OD‘s
monitoring of the centers‘ operations and programmatic activities, and
ensure that the agency‘s strategic and human capital planning are
coordinated and done expeditiously. CDC responded with a series of
actions to address these recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-04-219.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Marjorie E. Kanof at
(202) 512-7101.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Despite the Merit of Some Changes, CDC's Executive Structure Is Not
Well Aligned to Oversee Centers' Programmatic Work:
OD Has Improved Oversight of Public Health Emergencies, but Concerns
Remain about Oversight of Ongoing Agency Activities:
Planning Tools That OD Needs to Manage Agency Priorities and Human
Capital Challenges Are Not Yet Operational:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Centers for Disease Control and
Prevention:
Table:
Table 1: OD's Organizational Themes and Corresponding OD Management
Positions:
Figures:
Figure 1: CDC's Funding and FTE Growth from Fiscal Years 1946 to 2003:
Figure 2: Principal Locations of CDC Employees within the United
States:
Figure 3: CDC Organization Chart as of November 1, 2003:
Figure 4: OD Management Team Below the Director as of November 1, 2003:
Figure 5: Senior Officials Reporting to CDC's Director as of November
1, 2003:
Figure 6: Timeline of High-Profile Public Health Events and Emergencies
Requiring CDC Response:
Abbreviations:
ATSDR: Agency for Toxic Substances and Disease Registry:
CDC: Centers for Disease Control and Prevention:
COO: Chief Operating Officer:
FTE: full-time equivalent:
GPRA: Government Performance and Results Act of 1993:
HHS: Department of Health and Human Services:
NCEH: National Center for Environmental Health:
OD: Office of the Director:
OTPER: Office of Terrorism Preparedness and Emergency Response:
SARS: severe acute respiratory syndrome:
United States General Accounting Office:
Washington, DC 20548:
January 30, 2004:
The Honorable Julie L. Gerberding, MD, MPH:
Director, Centers for Disease Control and Prevention:
Dear Dr. Gerberding:
As the national focal point for conducting disease prevention and
control efforts, the Centers for Disease Control and Prevention (CDC)
is widely recognized for its work in investigating disease outbreaks as
well as its health promotion programs. Since it was established in
1946, CDC's scope of work has evolved from a narrow focus on malaria
control and other communicable diseases to a wide and complex range of
public health responsibilities. Today, CDC's mission is "to promote
health and quality of life by preventing and controlling disease,
injury, and disability." Establishing and maintaining balance within
this broad mission is an ongoing challenge for agency management. CDC,
an agency in the Department of Health and Human Services (HHS), has the
lead federal role in responding to infectious disease outbreaks, such
as severe acute respiratory syndrome (SARS), monkeypox, and the West
Nile virus. The agency is also responsible for addressing nonemergency
public health concerns, such as chronic diseases (including heart
disease, cancer, and diabetes), childhood immunizations, and
environmental and occupational health matters.
CDC's agency management responsibilities are considerable. In fiscal
year 2003, CDC managed a budget of almost $7 billion and its full-time
equivalent (FTE) staff numbered more than 8,800. Most of the agency's
staff are distributed across 11 centers, which are located at multiple
sites.[Footnote 1] The centers are responsible for working with the
agency's external partners--which include state, local, and
international public health agencies, among others--to carry out a
range of public health activities. In addition, CDC's Director serves
as the administrator of HHS's Agency for Toxic Substances and Disease
Registry (ATSDR), which focuses on environmental health-related issues.
CDC's top office, the Office of the Director (OD), has overall
management responsibility for CDC and ATSDR.
Over the past few years, concerns have surfaced about aspects of the
agency's management, beginning with weaknesses identified in the
financial management area. A 1999 study by the HHS's Office of
Inspector General stated that one of CDC's centers failed to report the
redirection of some of its funds--a problem that highlighted
shortcomings in top management's knowledge about center
operations.[Footnote 2] In 2000, we reported that CDC's financial
management capabilities had not kept pace with the agency's expanded
mission and increased funding and that financial management was not a
high priority relative to the agency's other functions.[Footnote 3]
That same year, after the public health community's response to the
first outbreak of the West Nile virus, we reported that public health
preparedness could be improved, in part, through better communication
among public health agencies, including CDC.[Footnote 4] During the
2001 anthrax incidents, the agency garnered criticism for its slow
release of important information. In 2002, we subsequently reported
internal management control weaknesses with CDC's oversight of the
Select Agent Program, which is responsible for regulating the transfer
of certain biological agents and toxins--such as anthrax--to
appropriate laboratories.[Footnote 5]
In the wake of the anthrax incidents and SARS outbreak, CDC has emerged
as a key player in preparing the nation for public health emergencies.
In 2002, the agency's OD spearheaded a number of initiatives aimed at
organizational change. Such change is necessarily a long-term
undertaking, requiring leadership and commitment. Experience shows that
successful major change management initiatives in large private and
public sector organizations can often take at least 5 to 7 years. This
length of time and the frequent turnover of political leadership in the
federal government have often made it difficult to obtain the sustained
and inspired attention to make needed changes.[Footnote 6] At this
time, OD's structural and management changes are relatively new. This
report examines the extent to which these changes have helped balance
OD's oversight of the agency's emergent and ongoing public health
responsibilities. Specifically, it examines OD's (1) executive
management structure, (2) approach to overseeing the agency's work, and
(3) approach to setting the agency's priorities.
In performing our review, we interviewed CDC senior executives within
OD. We also met with senior managers responsible for agency operations
and selected senior managers in six of the agency's centers and ATSDR.
We analyzed pertinent agency documents and interviewed officials at
state and local health departments, health-care-related associations,
nonprofit organizations, private industry, and schools of public
health. We performed our work from June 2002 through January 2004 in
accordance with generally accepted government auditing standards. (See
app. I for further detail.):
Results in Brief:
The management team in CDC's top office--OD--is undergoing a structural
change designed to provide a new approach to managing the agency's
public health work. Through this effort, CDC has taken steps that have
merit. For example, OD established a Chief Operating Officer (COO)
position with clear oversight authority for the agency's operations
units, such as financial management and information technology.
However, a significant oversight weakness remains: no similar position
or combination of positions on OD's management team below the
Director's level has been established to oversee the programs and
activities of the centers, which perform the bulk of the agency's
public health work. Only CDC's Director has line authority for the
centers, and the extraordinary demands on the Director's time
associated with public health emergencies and other external events
make the practicality of this oversight arrangement uncertain. Another
of OD's structural initiatives was to align OD management team
positions with five broad mission "themes," or goals, that cut across
the institutional boundaries of the centers. The intent was to foster
among CDC's 11 independent centers a more integrated approach to
performing the agency's mission. This purpose may be difficult to
realize, however, as connections between certain themes and associated
OD positions are not sufficiently clear.
OD has made significant improvements in directing the agency's response
to public health emergencies, but concerns remain about OD's oversight
of nonemergency public health work. An emergency preparedness and
response office was created in OD that, during the SARS outbreak,
successfully coordinated the response efforts of CDC's various centers
and OD staff offices. OD's communications office also developed an
emergency communication system that facilitates coordination among
specialists agencywide so that they can act in concert during public
health emergencies. However, OD continues to face challenges in
monitoring the agency's ongoing programmatic activities. Historically,
OD has operated in an environment in which--outside of routine
management meetings--its communication with center management
officials was largely informal and relied substantially on personal
relationships. Currently, OD's efforts to monitor the centers are still
not sufficiently systematic. For example, few formal systems are in
place to track the status of centers' activities and develop strategies
to mitigate adverse consequences in the event that some activities fall
behind schedule. Although OD has a process for center officials to
elevate important issues, the information flow under this process is
largely center-driven, as the subjects discussed are typically raised
at the discretion of the center officials. OD has not established its
own criteria specifying the type of matters warranting management input
or the time frames for reporting such matters. Similarly, OD's efforts
to foster coordination among the centers as a standard agency practice
for nonemergency public health work fall short of institutionalizing
such collaboration.
The planning tools that OD needs to set agency priorities, including
addressing human capital challenges, are under development. In recent
years, OD has operated without an up-to-date agencywide planning
strategy with which to set mission priorities and unify the work of
CDC's various centers. In June 2003, OD initiated an agencywide
strategic planning process. In a separate planning effort initiated in
April 2003, CDC began developing a human capital plan for meeting the
agency's current and future staffing needs. This effort has been
suspended while the strategic planning process gets under way, and no
time frames have been established for resuming its development. At the
same time, agency attrition and future limits on workforce growth
suggest that agency leadership may be needed to ensure that workforce
planning occurs expeditiously.
In light of OD's management challenges, we are making several
recommendations to the CDC Director. These include ensuring OD's
oversight of the centers' programmatic work at a level below the
Director, improving OD's monitoring of the centers' operations and
programmatic activities, and ensuring that the agency's strategic and
human capital planning are coordinated and done expeditiously. In
commenting on a draft of this report, CDC listed a series of actions it
would take for each recommendation, such as evaluating OD's oversight
structure, instituting formal reporting requirements and tracking
systems, and linking human capital planning and deployment with the
agency's strategic plan.
Background:
CDC is one of the major operating components of HHS, which acts as the
federal government's principal agency for protecting the health of all
Americans.[Footnote 7] CDC serves as the national focal point for
developing and applying disease prevention and control, environmental
health, and health promotion and education activities designed to
improve the health of Americans. CDC is also responsible for leading
national efforts to detect, respond to, and prevent illnesses and
injuries that result from the release of biological, chemical, or
radiological agents.
CDC was originally established in 1946 as the Communicable Disease
Center with the mission to help state and local health officials in the
fight against malaria, typhus, and other communicable diseases. Over
the years, CDC's mission and scope of work have continued to expand in
concert with public health needs. Commensurate with its increased scope
of work, CDC's budget and staff have grown. In 1946, the agency had a
budget of about $1 million and had over 360 FTEs. In fiscal year 2003,
CDC managed a budget of almost $7 billion and had over 8,800 FTEs. (See
fig. 1.):
Figure 1: CDC's Funding and FTE Growth from Fiscal Years 1946 to 2003:
[See PDF for image]
Note: GAO analysis of CDC data.
[A] We adjusted each of the budget numbers using a chain-type Gross
Domestic Product Price Index and an estimate for 2003 provided by the
Congressional Budget Office because fiscal year 2003 had not ended at
the time these calculations were made.
[B] FTE data are for 1961.
[End of figure]
To achieve its mission, CDC relies on an array of external partners,
including public health associations, state and local public health
agencies, schools and universities, nonprofit and volunteer
organizations, international health organizations, and others. CDC
collaborates with these partners to monitor the public's health, detect
and investigate disease outbreaks, conduct research to enhance
prevention, develop and advocate public health policies, implement
prevention strategies, promote healthy behaviors, foster safe and
healthful environments, and provide training. CDC provides varying
levels of support to its partners through funding, technical
assistance, information sharing, and personnel. In fiscal year 2002,
CDC awarded 69 percent of its total budget to partners through
financial assistance, such as cooperative agreements and
grants.[Footnote 8] The majority of these funds--about 75 percent--were
disbursed to state health departments. The remaining 25 percent of
these funds were disbursed to various other public and private
entities.
CDC's workforce consists of 170 job occupations including physicians,
statisticians, epidemiologists, laboratory experts, behavioral
scientists, and health communicators. Seventy-eight percent of CDC's
workforce consists of permanent civil service staff. U.S. Public Health
Service Commissioned Corps employees account for 10 percent of the
workforce, and temporary employees make up the remaining 12
percent.[Footnote 9] Most of CDC's staff are dispersed across over 30
locations in Atlanta, Georgia. CDC also has more than 2,000 employees
at other locations in the United States. (See fig. 2.) Additional CDC
staff are deployed to more than 37 foreign countries, assigned to 47
state health departments, and dispersed to numerous local health
agencies on both short-and long-term assignments.
Figure 2: Principal Locations of CDC Employees within the United
States:
[See PDF for image]
[A] These CDC facilities are quarantine stations located at major
international airports. CDC staff at these locations make and enforce
regulations necessary to prevent the introduction, transmission, or
spread of communicable diseases from foreign countries into the United
States. There is also a quarantine station located at the international
airport in Atlanta, the city where CDC is headquartered.
[End of figure]
CDC's organization consists of OD and 11 centers. OD consists of the
CDC Director's office and 12 separate staff offices. (See fig. 3.) OD
manages and directs the agency's activities; provides overall direction
to, and coordination of, its scientific and medical programs; and
provides leadership, coordination, and assessment of administrative
management activities. The individual OD staff offices are responsible
for managing crosscutting scientific functions, such as global health
and minority health, as well as support functions, including financial
management, grants management, human capital, and information
technology.
Figure 3: CDC Organization Chart as of November 1, 2003:
[See PDF for image]
[End of figure]
Each of CDC's centers interacts with the agency's external partners by
providing various means of assistance, such as funding and training.
Each center has an organizational structure that includes a director's
office, programmatic divisions, and branches, in most cases. The
centers also have their own budgets, which they administer. Eight of
the centers have their own mission statements, and several have
developed their own strategic plans.
CDC also performs many of the administrative functions for ATSDR. The
Director of CDC serves as the Administrator of ATSDR, which was
established within the Public Health Service by the Comprehensive
Environmental Response, Compensation, and Liability Act of
1980.[Footnote 10] ATSDR works to prevent exposures to hazardous wastes
and environmental spills of hazardous substances. Headquartered in
Atlanta, the agency has 10 regional offices and an office in
Washington, D.C. It also has a multidisciplinary staff of about 400
employees. For many years, ATSDR has worked closely with CDC's National
Center for Environmental Health (NCEH), which is responsible for
providing national leadership in preventing and controlling disease
associated with environmental causes. To foster greater efficiency,
NCEH and ATSDR signed a statement of intent in January 2003 to
consolidate their administrative and management functions for financial
savings. In August 2003, CDC's OD announced HHS's approval for a single
director to lead both ATSDR and NCEH. Final approval of this
consolidation effort was completed on December 16, 2003.
Despite the Merit of Some Changes, CDC's Executive Structure Is Not
Well Aligned to Oversee Centers' Programmatic Work:
The restructuring of the executive management team in CDC's top office,
despite certain merits, has shortcomings with respect to agency
oversight. A positive OD change made in 2003 was the assignment of an
OD official other than the agency's Director to provide oversight
authority for the agency's operations units, such as financial
management and information technology. However, no OD official, other
than the Director, has explicit responsibility for overseeing the
centers' programmatic work. Another positive change made in 2003 was to
align OD management team positions with broad agency mission themes
that cut across individual programs and organizational units. However,
despite the intention for the themes to foster collaboration among
CDC's 11 centers and with its external partners, clear connections
between the management team's deputy positions, the mission themes, and
agency mission activities have not been made.
OD's Structure for Overseeing Centers' Programmatic Work Raises
Concerns:
In January 2003, as part of the agency's transformation efforts, CDC's
Director announced an OD management team consisting of five senior
officials, including a COO, two deputies, a senior advisor, and a Chief
of Staff. A beneficial change in OD's structure was the creation of a
COO with clear oversight authority over the agency's operations units,
positioning OD to oversee these areas appropriately. However, no
similar position or combination of positions has been established in OD
to oversee the programs and activities of the centers, as no one below
the Director on OD's management team has direct line authority for the
centers' programmatic work. This also holds true for the three
officials added to the OD management team as of fall 2003--the Director
of the CDC Washington Office, the Senior Advisor to the Director, and
the Associate Director for Terrorism Preparedness and Response. (See
fig. 4.):
Figure 4: OD Management Team Below the Director as of November 1, 2003:
[See PDF for image]
Note: GAO analysis of CDC data.
[A] Staff reporting to the COO, who heads the office, include the
Deputy COO, the Chief Information Officer, and the Chief Financial
Officer.
[B] Staff reporting to the Director of the CDC Washington Office
include a deputy director.
[C] Staff reporting to the Associate Director for Terrorism
Preparedness and Response include two deputy directors and an associate
director.
[End of figure]
A look at the roles of OD's management team highlights a structural
weakness in oversight authority for the centers' programmatic work.
* COO. This official has oversight responsibility for the agency's core
business operations, including financial management, procurement and
grants, human resources, and information technology, among others.
CDC's COO is consistent with a commonly agreed-upon governance
principle that "a single point" within an agency should have the
responsibility and authority for the agency's management
functions.[Footnote 11] It also parallels the experience of successful
organizations that place this type of management position among the
agency's top leadership.[Footnote 12]
* Deputy Director for Science and Public Health and Deputy Director for
Public Health Service. These officials function largely as technical
advisors, working with the centers on various issues but having no
oversight responsibility for them. Five OD offices report directly to
the Deputy Director for Science and Public Health. No offices report
directly to the Deputy Director for Public Health Service.
* The Senior Advisor for Strategy and Innovation. This advisor is
responsible for the agency's strategic planning efforts and, apart from
the official's own office staff, has no direct reports.
* Chief of Staff. The Chief of Staff serves as a principal advisor and
assistant to the Director and is responsible for OD's day-to-day
management. This responsibility includes routing to the appropriate OD
or center official the agency's incoming inquiries or requests from the
Congress, the administration, and the public health community. Two OD
offices report directly to the Chief of Staff--the Office of the
Executive Secretariat[Footnote 13] and the Office of Program Planning
and Evaluation.[Footnote 14]
* Director, CDC Washington Office. This official manages the CDC
Washington Office, which acts as a liaison between CDC and its
Washington-based stakeholders, which include other agencies,
associations, policymakers, and others interested in public health.
* Senior Advisor to the Director. This advisor is responsible for
providing research, analysis, outreach activities, and strategy
formulation to meet the needs of the Director and, apart from the
official's own office staff, has no direct reports.
* Associate Director for Terrorism Preparedness and Response. This
official's responsibilities include managing OD's Office of Terrorism
Preparedness and Emergency Response (OTPER) as well as CDC's national
bioterrorism program.
As of November 1, 2003, a total of 20 officials, including the 11
center directors, reported to the CDC Director. (See fig. 5.):
Figure 5: Senior Officials Reporting to CDC's Director as of November
1, 2003:
[See PDF for image]
Note: GAO analysis of CDC data.
[A] As of August 18, 2003, the Director of NCEH became a Senior Advisor
within OD, and the Director of ATSDR became the head of the
consolidated management and administrative structure for ATSDR and
NCEH.
[B] Although this official reports to the CDC Director, the official is
not a member of the OD management team.
[End of figure]
Whether this structural arrangement can support effective oversight of
the agency's programmatic work is uncertain, given the growth in the
demands on the CDC Director's time along with the likely change in
directors over time. Since the first West Nile virus outbreak in 1999,
CDC has responded to a steady stream of high-profile public health
emergencies, including the anthrax incidents and the more recent
outbreak of SARS. (See fig. 6.) Responding to these events has required
the focused attention of the CDC Director. In addition, routine demands
on the Director's time--such as testifying before the Congress,
coordinating with HHS officials, and meeting with other national and
international public health officials--subtract from the time the
Director has to oversee the centers, which perform the core of CDC's
mission work.
Figure 6: Timeline of High-Profile Public Health Events and Emergencies
Requiring CDC Response:
[See PDF for image]
Note: GAO analysis of CDC data.
[End of figure]
The typical change in politically appointed agency heads every several
years is another factor that makes center oversight solely by the
Director a management vulnerability. CDC has had four directors,
including the current one, since 1990. While there is nothing uncommon
or irregular about such change, it is significant from a management
perspective, as agency heads typically need time to acclimate to their
new responsibilities and may not stay in office long enough to
institutionalize management improvements.
Unclear Roles and Responsibilities of OD Deputy Positions Slow
Intention to Integrate Center Activities around Themes:
Despite the restructuring of OD to reflect agency mission themes, this
effort falls short of its intention, owing to a lack of clarity and
definition in the roles of the OD deputies. CDC's Director established
five mission themes, or goals--science, strategy, service, systems, and
security. The intention was to acknowledge that shared goals cut across
the agency's diverse centers and that viewing the work in this way
could foster collaboration. The new OD structure announced in January
2003 aligned executive management positions with each of the themes.
(See table 1.):
Table 1: OD's Organizational Themes and Corresponding OD Management
Positions:
Themes: Excellence in Science: Practice evidence-based science grounded
in sound peer-reviewed research; Positions: Deputy Director for
Science and Public Health.
Themes: Excellence in Service: Promote efficient service to meet the
needs of partners and customers; Positions: Deputy Director for Public
Health Service.
Themes: Excellence in Systems: Fine-tune and manage systems so that
personnel, technology, infrastructure, and information are used
efficiently to achieve results; Positions: Chief Operating Officer.
Themes: Excellence in Strategy: Ensure that strategies prepare agency
for future challenges; Positions: Senior Advisor for Strategy and
Innovation.
Themes: Excellence in Security: Ensure public health preparedness and
support response efforts; Positions: Associate Director for Terrorism
Preparedness and Response[A].
Source: CDC.
[A] Although this position and its corresponding theme were also
announced in January 2003, this official was not a member of the OD
management team until October 2003.
[End of table]
The distinction between the roles of the two deputy positions--Deputy
Director for Science and Public Health and Deputy Director for Public
Health Service--has not been clearly made. The role of the Deputy
Director for Science and Public Health is to serve as OD's contact
point to the centers in areas including agency reports, guidelines and
recommendations, and outbreak investigations. However, this deputy's
role is not distinct from that of the Deputy Director for Public Health
Service, who serves as OD's liaison to public health agencies and other
external partners as well as OD's contact point for certain scientific
issues, including HIV policies, occupational safety and health
policies, injury and violence prevention policies, and programs to
address public health disparities. Addressing public health
disparities, however, is the mission of CDC's Office of Minority
Health, which reports to the other deputy--the Deputy Director for
Science and Public Health. Furthermore, some center officials said that
regarding science-related issues involving CDC's external partners,
they were uncertain whether the primary point of contact should be the
Deputy Director for Science and Public Health or the Deputy Director
for Public Health Service.
OD Has Improved Oversight of Public Health Emergencies, but Concerns
Remain about Oversight of Ongoing Agency Activities:
OD has implemented several changes in its approach to managing the
agency's response to public health emergencies, including the creation
within OD of an emergency operations office that, during the SARS
outbreak, successfully coordinated the response efforts of CDC's
various centers and staff offices. However, concerns remain about OD's
management of ongoing agency activities, as few systems are in place to
provide top agency officials with essential oversight information or to
foster collaboration among the centers.
OD Has Improved Its Ability to Oversee the Agency's Response to Public
Health Emergencies:
In recognition of past problems, OD initiated several structural and
procedural changes that improved its ability to oversee the agency's
response to public health emergencies. Specifically, the 2001 anthrax
incidents revealed weaknesses in the agency's ability to coordinate
internal response efforts and in its efforts to communicate with the
nation's public health agencies, medical communities, and other
external partners--a problem that had also been identified during the
response to the first West Nile virus outbreak in 1999. Agency
officials and external partners recognized several problems that needed
to be addressed:
* A top OD official we spoke with noted that during the anthrax
incidents, the agency leadership lacked formal protocols for making
crisis management decisions. This official stated that over 100 staff
attended internal information briefings; in this official's view, the
volume and diversity of information presented to agency management at
these briefings resulted in "information overload" that impeded timely
decision making.
* An internal CDC document noted that as of October 2001, CDC was
running four separate emergency operation centers, resulting in an
uncoordinated command and control environment. Prior to September 11,
2001, CDC operated two loosely connected emergency operations centers-
-one in NCEH and one in ATSDR.[Footnote 15] After the terrorist attacks
on September 11, 2001, CDC established two additional emergency
operations centers in the National Center for Infectious Diseases and
the Public Health Practice Program Office. The internal document
asserted that after the subsequent anthrax incidents, CDC's multiple
emergency operation centers could not provide the agencywide
coordinated effort needed to address a crisis.
* A variety of external partners we spoke with criticized CDC's
response to the anthrax incidents for its failure to quickly
communicate vital information to the public and to the health care
workers responsible for diagnosing and treating suspected cases.
Likewise, we recently reported that although CDC served as the focal
point for communicating critical information during the response to the
anthrax incidents, it experienced difficulty in managing the voluminous
amounts of information coming into the agency and in communicating with
public health officials, the media, and the public.[Footnote 16]
* A top OD official contended that during the response to the anthrax
incidents, the agency would have had difficulty responding to another
public health emergency, since key personnel and resources drawn from
the various centers and OD staff offices were consumed by this effort.
In response to these weaknesses, CDC instituted several organizational
changes. In August 2002, CDC created OTPER within OD to be headed by
the Associate Director for Terrorism Preparedness and Response, who
reports to the CDC Director. The office is responsible for coordinating
agencywide preparedness and response efforts among the agency's centers
and its partners. Agency officials told us that the elevation of this
responsibility to OD was necessary because of unsuccessful past efforts
to ensure coordination among the centers. This office also has
responsibility for specific aspects of information systems, training,
planning, communications, and preparedness activities designed to
facilitate the agency's emergency response effectiveness. In addition,
it provides financial and technical assistance for terrorism
preparedness to state, local, and U.S. territorial health departments.
In fiscal year 2002, OTPER disbursed about $1 billion in financial
assistance to these partners.
To improve the agency's response effectiveness, OTPER developed
management decision and information flow models, which outline who will
be involved and how the emergency will be handled from strategic,
operational, and tactical perspectives. According to the Associate
Director for Terrorism Preparedness and Response, these models were
used to manage the emergencies involving SARS, monkeypox, and potential
terrorist acts associated with the war in Iraq. OTPER also drafted
CDC's national public health strategy for terrorism preparedness and
response, including an internal management companion guide on
implementation. CDC intends to distribute this document to the agency's
external partners.
OTPER manages CDC's recently constructed emergency operations center,
where all aspects of the agency's emergency response efforts are
coordinated. This center is intended to provide a central command-and-
control focal point and eliminate the need to coordinate efforts of
multiple centers during emergencies. According to the Associate
Director for Terrorism Preparedness and Response, the emergency
operations center is operational around the clock and has a small
number of dedicated staff. In times of emergency, subject matter and
communication experts from the centers are temporarily detailed for 3
to 6 months as needed. For example, during the SARS response,
individuals from the National Center for Infectious Diseases, the
National Institute for Occupational Safety and Health, the Epidemiology
Program Office, and the Global Health Office, among others, staffed the
emergency operations center and returned to normal duties at
predetermined intervals to mitigate any major impact on routine public
health work. This logistical approach to staffing and resources was
intended to enable CDC to respond to multiple public health
emergencies, if needed.
Within OD, the Office of Communication works with OTPER to facilitate
external communications during public health emergencies. In August
2002, this office established an emergency communication system to
enhance CDC's ability to disseminate timely and reliable information.
This system consists of 10 teams that include agency staff from various
units who can be called on to act in concert during public health
emergencies. Each team has a particular focus--such as media relations,
telephone hotline information, Web site updates, and clinician
communication. In June 2003, CDC named an Emergency Communication
System Coordinator to provide day-to-day oversight of the teams.
OD Faces Challenges in Overseeing Nonemergency Public Health Work:
Despite improvements to crisis management, OD faces challenges in
managing its nonemergency public health work. Typically, the attention
of OD's top officials has been focused on emergent public health
issues, such as infectious disease outbreaks, leaving little time for
focusing on nonemergency public health work and agency operations. OD
has also operated in an environment that until recently had not
significantly evolved from the time when the agency was smaller and its
focus was narrower; outside of routine management meetings, OD's
communication with the centers was largely informal and relied
substantially on personal relationships. As a result, the centers have
operated with a high degree of independence and latitude in managing
their operations.
Few Tracking Systems Are in Place to Provide Management Oversight
Information:
OD has few systems in place with which to track agency operations and
programmatic activities. As of summer 2002, OD management officials
received only limited management information regularly--monthly
reports on budget obligations, a weekly legislative report, a weekly
media relations report, and a weekly summary workforce report. Over the
past year, OD has taken steps to obtain additional management
information and has begun to track some aspects of center operations.
* As of April 2003, a weekly summary report on congressional activities
that supplements the weekly legislative report has been provided to OD
management team officials.
* In fall 2003, OD began compiling a weekly list of selected CDC
publications, correspondence, and activities.
* The COO began monitoring the centers' travel and training
expenditures on an ad hoc basis after conducting a benchmarking
analysis on the centers' fiscal year 2002 expenditures in these areas.
Previously, scrutiny of these expenditures was at the discretion of
center management.
OD has not made similar efforts to monitor the agency's programmatic
work. Outside of routine management meetings with the centers, OD
continues to lack formal reporting systems needed to track the status
of the centers' public health programs and develop strategies to
mitigate adverse consequences in the event that some activities fall
behind schedule.
OD relies on its issues management process as one way to stay informed
of the centers' important but nonemergency issues.[Footnote 17]
Historically, the center directors, accustomed to operating
autonomously, had little precedent for raising issues for OD management
input. In January 2003, OD instituted the issues management process,
which, among other things, sought to encourage center officials to
elevate significant matters that are not national emergencies but that
warrant timely input from the agency's senior managers. Under this
process, a center official seeking management input on an issue of
concern contacts OD's Chief of Staff, who is responsible for
coordinating agency input on the issue. The Chief of Staff identifies
the appropriate senior officials for handling the concern and tracks
actions taken until the matter is concluded. Emerging issues that
centers have raised through this process include the agency's HIV
prevention initiatives, preparedness activities for the West Nile
virus, and wild animal trade restrictions subsequent to the monkeypox
outbreak.
According to the Chief of Staff, the issues management process has
provided an effective communication channel for the center directors,
as it has enabled them to have regular contact with OD management and
the CDC Director, as needed. As an effective OD oversight tool,
however, the issues management process is incomplete. Under this
process, OD has not established formal criteria--in the form of
reporting requirements--that would instruct centers on what types of
issues warrant management input and the time frames for reporting them.
Instead, OD relies largely on the center directors' discretion to
determine which nonemergency public health issues are made known to the
agency's top management. In this regard, the issues management process
remains essentially a bottom-up approach to obtaining information on
CDC center activities. Coupled with a lack of management reporting
systems, this approach places OD in a reactive rather than leadership
position with respect to the centers and the public health work they
manage.
OD Efforts to Foster Collaboration among Centers Are Incomplete:
While OD has taken steps to improve the centers' ability to effectively
collaborate during emergencies, more needs to be done for collaboration
on nonemergency public health work. The centers have historically not
coordinated well on nonemergency public health issues common to
multiple centers--a situation we reported on in February 1999.[Footnote
18] OD officials have also acknowledged that the centers operate as
"silos," characterizing the isolated manner in which these separate but
related organizational components operate.
OD has taken several steps to foster center collaboration on
nonemergency public health work. Conceptually, OD's emphasis on the
five themes--science, service, systems, strategy, and security--is part
of an approach to integrate the agency's public health work across the
centers' respective missions and functions. In August 2003, OD
announced the establishment of two governing bodies that encourage
center collaboration--the Executive Leadership Team and the Management
Council. The Executive Leadership Team, which includes the OD
management team and each of the center's directors, meets biweekly and
seeks to ensure that coordination occurs across centers and that the
centers' interests are not omitted when key decisions are being
considered by the agency's top officials. The Management Council, which
also meets biweekly, focuses on crosscutting issues involving agency
operations, such as information technology. The council is chaired by
OD's COO and is composed of staff office officials and representatives
from each of the centers. In providing recommendations to the Executive
Leadership Team on agency operations issues, such as the development of
performance metrics and the consolidation of the agency's information
technology infrastructure, the council has the opportunity to foster
more consistent management practices across the agency.
OD officials acknowledged that along with these efforts to promote
collaboration, additional initiatives are needed to ensure that
collaboration among the centers becomes a standard agency practice.
Such efforts by leading organizations to institutionalize collaboration
include, for example, the design of cross-functional, or "matrixed,"
teams; pay and other incentive programs linked to achieving mission
goals; and performance agreements for senior executives that specify
fostering collaboration across organizational boundaries.[Footnote 19]
Planning Tools That OD Needs to Manage Agency Priorities and Human
Capital Challenges Are Not Yet Operational:
In recent years, CDC's OD has operated without an up-to-date agencywide
planning strategy with which to set agency mission priorities and unify
the work of its various centers. In June 2003, OD initiated an
agencywide strategic planning process. Shortly before this, in April
2003, OD began developing a human capital plan for current and future
staffing priorities, but the plan has been put on hold until the
agencywide planning strategy has been established.
OD's Priority-Setting Efforts Have Lacked a Long-Term Focus:
CDC has a strategic plan that has not been updated since 1994.
Consequently, this plan does not reflect the agency's more recent
challenges, such as preparing for terrorism-related events and
implementing the civilian portion of the national smallpox vaccination
campaign. In the absence of a current long-term strategy, OD has been
establishing priorities within its diverse mission through the annual
processes for developing the budget and updating goals for the agency's
annual performance report as required by the Government Performance and
Results Act of 1993 (GPRA). This method for setting priorities is not
effective for long-term planning, as its focus is on funding existing
activities one year at a time rather than examining agency goals and
performance from a broader perspective.
CDC's need for a comprehensive strategic plan is substantial, as OD
must set priorities based on disease prevention and control objectives
inherent in the agency's mission as well as any additional public
health priorities of HHS and the Congress. For example, in addition to
addressing public health program priorities, such as obesity and
diabetes, CDC must also address administration management priorities as
directed by HHS.[Footnote 20] Moreover, the agency must keep a mission
focus when coordinating with its external partners--largely, state,
local, and international public health agencies. Although CDC relies
heavily on these and other external partners to achieve its mission, a
mutual understanding of the agency's priorities may be lacking. For
example, some of the state and local public health officials we spoke
with were unable to articulate the agency's top priorities aside from
bioterrorism preparedness. CDC officials we spoke with similarly
acknowledged the need to better communicate priorities to external
partners.
Many of the centers have their own mission statements and a few also
have strategic plans to address individual center goals and priorities-
-a reflection of the centers' independent focus. In the absence of an
agencywide plan, however, OD lacks an effective management tool to
ensure that the agency's priorities are being addressed without undue
overlap or duplication. In July 2003, participants in preliminary
strategic planning discussions acknowledged poor cooperation across
centers and the need for improvement in collaboration.
Strategic Planning Process Recently Initiated:
In June 2003, OD initiated an agencywide strategic planning process
called the Futures Initiative, which is intended to involve all levels
of staff and some of the agency's partners in developing long-range
goals and associated performance measures. The agency's strategic
planning efforts will be focused on 10 topics: the public health
system, customers' needs, research capacity, communication and
information priorities, future resource needs, government partner
relationships, measuring results, intra-agency coordination, programs
and grants portfolio, and global health issues. In developing the
strategy, OD intends to incorporate the agency's mission and vision,
the federal Healthy People 2010 goals, HHS's strategic goals and
objectives, and selected public health reports.[Footnote 21] However,
at the time of our review, OD had not clearly linked the 10 topics and
the agency's five mission themes of science, strategy, service,
systems, and security.
To guide and manage the agency's planning efforts, OD created a
steering committee, which is led by the agency's Director and consists
of a small group of senior officials from OD and the centers. This
committee makes recommendations to the Executive Leadership Team for
decision making. Under the committee, four initial work groups,
consisting of center representatives and some external partners, have
been established to examine the following topics: customers and
partners, health systems, health research, and global health.
CDC's overall strategic planning process has three phases. In the first
phase, CDC will evaluate the agency's overall direction and set
priorities. In the second, it will examine the agency's organizational
structure and processes and their alignment with the strategic plan's
goals and begin implementation. The last phase will focus on measuring
results and implementing the plan at all agency levels--both management
and staff. OD plans to begin implementing the strategy in spring 2004.
OD intends to communicate the results of the planning process
internally to staff and externally to agency partners through CDC's Web
site and through a variety of meetings and different venues.
According to the Senior Advisor for Strategy and Innovation, priority
issues and programs identified through the strategic planning process
will have goals, action plans, and outcome measures for tracking and
accountability. This official also stated that the expected result is
that the finished "strategy" will act as a framework for the individual
centers to align with and will guide CDC's priority setting, budget
formulation, and annual development of GPRA goals. For OD to
effectively lead the agency's efforts in implementing its long-term
strategy, it will be important to link the performance expectations of
senior management to the agency's organizational goals.[Footnote 22]
Human Capital Plan Initiated but Recently Suspended:
OD has been operating without a comprehensive human capital plan with
which to link workforce needs to agency priorities. The agency has
several separate initiatives under way in response to administration
directives regarding human capital management. However, in December
2002, HHS criticized these efforts as being overly focused on the
centers and lacking an agencywide focus. In April 2003, OD began
developing a comprehensive, long-term human capital plan. In July 2003,
OD suspended the development of this plan until further progress could
be made on the agency's strategic planning process. As of November
2003, OD had not established a date when the human capital planning
would resume nor determined how it would be coordinated with the
agency's strategic planning efforts.
Furthermore, CDC is facing several human capital challenges that
underscore the need for a strategy to address succession planning,
which involves preparing for the loss of key staff and their associated
skills. Leading organizations use succession planning and management as
a tool that focuses on current and future workforce needs in order to
meet their mission over the long term.[Footnote 23] Our analysis of
CDC's 2003 personnel data showed that--similar to the rest of the
federal government--about 30 percent of the agency's workforce is
eligible to retire within the next 5 years. We also found that 33
percent of its senior managers and supervisors will be eligible for
retirement within this time frame.[Footnote 24] Thus, within several
years, the agency could potentially lose a key portion of its human
capital that possesses both managerial and technical
expertise.[Footnote 25]
In addition, by the end of fiscal year 2005, CDC and other HHS agencies
are expected to achieve a departmentwide 15 percent reduction in
administrative management and support positions. HHS mandated that this
reduction not result in the involuntary separations of employees and
that affected resources be redirected to programmatic public health
work. The implications for CDC are that within a 2-year time frame, CDC
must redirect 573 administrative positions from support activities to
frontline public health program activities. In some cases, this would
involve redirecting administrative staff to program work. However, this
will pose a challenge for CDC, as the agency does not maintain a
repository of its employees' skills, which is important to ensure
appropriate employee placement. HHS has also directed each of its
agencies to assume no growth in the number of FTEs beginning with the
fiscal year 2005 budget formulation process and to include a 5 percent
FTE reduction option in their budget submissions.
OD has taken modest steps toward succession planning. For example, CDC
participates in HHS's program to train and mentor emerging leaders.
CDC's Director has also emphasized the importance of identifying future
leaders within the agency and has made this issue a standing agenda
item in routine management meetings with center officials. To forecast
workforce needs, in August 2002, the agency produced a report of
attrition for its offices and centers. Currently, CDC's managers can
access the most recent attrition data by querying a Web-based personnel
information system. However, OD is limited in its ability to conduct
targeted succession planning or promote greater retention, as it does
not track certain key personnel information. For example, although
resignations in calendar year 2002 accounted for a higher percentage of
the agency's attrition than retirement (30 percent compared with 20
percent),[Footnote 26] CDC does not systematically document the reasons
for resignations, either through standard "exit interviews" of
employees who leave the agency or some other means.[Footnote 27] This
lack of documentation limits OD's ability to conduct comprehensive
workforce planning, which includes strategies for retaining an
organization's workforce for meeting future needs.[Footnote 28]
The considerable succession planning challenges that the agency faces
argue for greater OD leadership over human capital planning. Such
leadership would be consistent with the effective human capital
planning actions of six federal agencies cited in our April 2003 report
on this subject.[Footnote 29] The report noted, among other things, the
importance of including human capital leaders in key agency decision
making and the establishment and communication of a strategic vision by
human capital leaders. Currently, CDC does not have, as envisioned in
these reported best practices, a top-level leadership position focused
on CDC's human capital efforts.
Conclusions:
To better position CDC as it grows and evolves, OD has embarked on a
number of changes to improve the agency's management and planning
efforts. While some of these changes have improved the agency's ability
to respond to recent public health emergencies, OD continues to face
challenges in overseeing its ongoing, nonemergency public health work.
First, a weakness in oversight of the centers exists, as only the CDC
Director has line authority over them, and it is uncertain whether this
arrangement provides for sufficient top management oversight of the
centers' programs and activities. In addition, the roles of OD's two
deputy directors lack the clarity needed for those seeking the
appropriate OD points of contact.
Second, OD lacks sufficiently systematic information to track agency
operations or the centers' core public health programs--placing agency
management in a reactive rather than leadership position. Despite
efforts made to encourage a better information flow between OD and the
centers, the reporting of important but nonemergency issues remains
largely at the discretion of the centers. Furthermore, efforts to
foster collaboration among centers for routine public health work have
been made, but little has been done to institutionalize such
collaboration and avoid undue overlap or duplication.
Third, OD is taking steps to manage the agency strategically, but key
planning tools are not fully in place. A recently announced strategic
planning process is intended to identify and communicate the agency's
optimal structure, processes, and performance measures. A human capital
plan was initiated in April 2003, but this effort has been postponed
while the strategic planning process gets under way. As of November
2003, no time frames had been established for resuming the development
of the human capital plan or coordinating it with the strategic
planning process. The newness of the agency's strategic planning
process and stalled workforce planning efforts argue for greater
leadership from OD to continue and coordinate both efforts.
Recommendations for Executive Action:
To improve OD's management of CDC's nonemergency mission priorities, we
recommend that the CDC Director take the following three actions:
* realign and clarify oversight responsibility for the centers'
programmatic work at a level below the Director, including clarifying
the roles of OD's deputy directors;
* ensure that reporting requirements and tracking systems are developed
for OD to routinely monitor the centers' operations and programmatic
activities; and:
* develop incentives to foster center collaboration as a standard
agency practice.
We also recommend that the CDC Director take the following two actions:
* ensure that the agency's new strategic planning process will involve
CDC employees and external partners to identify agencywide priorities,
align resources with these priorities, and facilitate the coordination
of the centers' mission-related activities and:
* ensure that the agency's human capital planning efforts receive
appropriate leadership attention, including resuming human capital
planning, linking these efforts to the agency's strategic plan, and
linking senior executives' performance contracts with the strategic
plan.
Agency Comments:
In its written response to a draft of this report, CDC stated that it
is committed to continuing the positive changes we highlighted in the
report and agreed that challenges remain--especially for ensuring
program accountability. CDC acknowledged that continued oversight from
OD is critical to ensure high-quality management practices and
scientific excellence. The agency further emphasized that it is in the
early stages of a multiyear process of change.
CDC stated that ensuring program accountability is a significant
challenge that it takes most seriously as stewards of the public's
trust and funding. The agency agreed to evaluate our recommendation to
realign and clarify oversight for the centers' programmatic work at a
level below the Director in light of the management changes the agency
has already undertaken. CDC also stated that it is working to institute
formal reporting requirements and tracking systems that monitor center
activities with special emphasis on program outputs, outcomes, and
impacts. In addition, CDC stated that it continues to seek ways to
strengthen center collaboration. The agency also agreed with our
recommendation regarding its strategic planning process and provided
information on how it has involved both internal employees and external
partners. CDC concurred that human capital planning is critically
important and stated that it will link human capital planning and
deployment to its strategic plan, and appropriately connect the
performance contracts of its senior executives with the developing
strategic plan. CDC also provided technical comments, which we
incorporated as appropriate. CDC's written comments are reprinted in
appendix II.
We are sending copies of this report to the Secretary of HHS. We will
also provide copies to others upon request. In addition, the report
will be available at no charge on GAO's Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please call
me at (202) 512-7101 or Bonnie Anderson at (404) 679-1900. Hannah Fein,
Cywandra King, and Julianna Williams also made key contributions to
this report.
Sincerely yours,
Marjorie E. Kanof:
Director, Health Care--Clinical Health Care Issues:
Signed by Marjorie E. Kanof:
[End of section]
Appendix I: Scope and Methodology:
To assess the Centers for Disease Control and Prevention's (CDC)
executive management structure, we analyzed past and current
organizational structures and reporting arrangements. We interviewed
the agency's Director about the basis of the management reorganization
and the roles of the officials in the Office of the Director's (OD)
management team. We also interviewed the consultant who worked with
agency management to help develop the new OD structure. To identify
changes resulting from the reorganization, we spoke with past and
current OD executive management officials to discuss their roles and
responsibilities, and we reviewed the position descriptions for these
officials. To ascertain the centers' understanding of the roles of the
OD management team, we interviewed management officials from the
following six centers: National Center for Chronic Disease Prevention
and Health Promotion; National Center for Environmental Health;
National Center for Health Statistics; National Center for Infectious
Diseases; National Center for HIV, STD, and TB Prevention; and Public
Health Practice Program Office. We also interviewed management
officials at the Agency for Toxic Substances and Disease Registry,
which functions similarly to CDC's centers. To assess the demands on
the Director's time, we identified high-profile public health events
and emergencies since the first West Nile outbreak in 1999. We also
analyzed the Director's calendar for the 7-month period covering
January 1, 2003, through July 27, 2003.[Footnote 30]
To evaluate OD's approach to managing the agency's response to public
health emergencies, we looked at CDC's emergency infrastructure and
communication processes. To identify changes CDC implemented to improve
its performance in this area, we interviewed senior management
officials within OD, including the Associate Director for Terrorism
Preparedness and Response. We reviewed documentation that included the
agency's decision models, its national public health strategy for
terrorism preparedness and response, and information about the Office
of Terrorism Preparedness and Emergency Response. We also reviewed
documentation about the agency's past emergency operations centers as
well as the recently constructed operations center, including how it is
staffed during times of emergency. To learn about CDC's emergency
communication system, we interviewed the Director of the Office of
Communication and reviewed pertinent documentation on the various
communication teams. We also spoke with some of CDC's partners to
obtain their views on how well the agency communicates during public
health emergencies.
To assess OD's approach to managing routine agency operations, we met
with OD executive management officials to determine the frequency and
types of communications among them. We also met with management
officials in six of the centers to discuss the frequency and type of
communications between them and OD. To identify the type of management
information OD received, we obtained copies of periodic management
reports. We also obtained a list of all management meetings, including
purpose, attendees, and frequency. We observed several management
meetings, including an OD planning meeting, a senior staff meeting, and
an issue briefing. We also attended agencywide staff meetings. In
addition, we spoke with senior officials of the following OD staff
offices: CDC Washington Office; Office of Communication; Financial
Management Office; Procurement and Grants Office; Human Resources
Management Office; Management Analysis and Services Office; and Office
of Program, Planning, and Evaluation. We discussed with these officials
the functions of their offices. We met with the Chief of Staff to
discuss the issues management process, which the agency uses to manage
issues requiring OD's attention, and its use by agency officials. We
obtained documentation of the corresponding issues tracking system as
well as a list of issues that have been or are going through the
process. To discuss how well the centers collaborate with one another,
we met with management officials within OD to obtain their views and to
identify steps taken by OD to improve the level of cooperation. We also
obtained the views of some of the agency's partners, who interact with
multiple centers. To determine how CDC collaborates with its partners,
we interviewed over 30 officials of state and local health departments,
health-care-related associations, nonprofit organizations, private
industry, schools of public health, and others, such as past CDC
directors. We also interviewed the Deputy Director of Public Health
Service to discuss how this official interacts with the agency's
partners. In addition, we reviewed relevant documentation, including an
internal assessment of CDC's customer service practices.
To identify OD's approach for setting the agency's priorities, we
interviewed senior management officials within OD and reviewed relevant
documentation, including the agency's 1994 strategic plan. In addition,
we spoke with some of the agency's partners to determine how CDC
communicates its priorities to them. To learn about CDC's recently
implemented strategic planning approach, we interviewed CDC's Senior
Advisor for Strategy and Innovation and reviewed extensive
documentation regarding this effort. We also attended agency meetings,
which introduced the strategic planning process to both CDC staff and
some of its advisors. We interviewed officials in CDC's human resource
office to discuss the agency's workforce planning efforts. We also
reviewed relevant documentation, including internal workforce planning
reports, reports to the Department of Health and Human Services (HHS),
feedback from HHS, and analyses performed by the agency's contractor
for the development of a human capital plan. We obtained and analyzed
agency data on overall attrition and retirement eligibility. We also
calculated retirement eligibility specifically for management-level
staff. We discussed the limitations of the data with the appropriate
CDC official and determined that the data were suitable for our use.
Furthermore, we analyzed HHS directives that will potentially affect
the size and composition of CDC's workforce and discussed their
implications with OD management officials.
[End of section]
Appendix II: Comments from the Centers for Disease Control and
Prevention:
DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service:
Centers for Disease Control and Prevention (CDC)
Atlanta GA 30333:
* DEC 22 2003:
Marjorie E. Kanof, M.D., M.P.H.
Director, Health Care - Clinical Health Care Issues:
United States General Accounting Office
441 G Street, N.W., Room 5104
Washington, D. C. 20548:
Dear Dr. Kanof:
Enclosed are the Centers for Disease Control and Prevention's (CDC)
comments on your draft report (GAO-04-219), "Centers for Disease
Control and Prevention: Agency Leadership Taking Steps to Improve
Management and Planning, But Challenges Remain. ":
The agency is providing technical comments directly to your staff.
CDC appreciates the opportunity to comment on this draft report before
its publication. CDC also recognizes the General Accounting Office's
diligent effort over the past 18 months to review CDC's evolving
management actions.
Sincerely,
Julie Louise Gerberding M.D., M.P.H.:
Director:
Signed by Julie Louise Gerberding:
Enclosure:
Comments from the Centers for Disease Control and Prevention on the U.
S. General Accounting Office (GAO) Draft Report "Centers for Disease
Control and Prevention: Agency Leadership Taking Steps to Improve
Management and Planning. But Challenges Remain" (GAO-64-219):
General Comments:
The Centers for Disease Control and Prevention (CDC) welcomes GAO's
positive evaluation of CDC's management and strategic planning
initiatives. As the report highlights, initiatives encompassing
significant management changes, like those CDC is undertaking, can
require at least 5 to 7 years to complete. When the agency began the
strategic change process, CDC senior managers understood that this
process, the Futures Initiative, would require substantial time. CDC is
tremendously encouraged that GAO has documented dramatic changes that
the agency has made over the last 12 months, and CDC is committed to
continuing the positive changes GAO spotlighted. These changes will
further improve the agency's ability to address its vital public health
mission and, ultimately, positively affect the health of the American
people.
GAO highlighted CDC's substantial improvements in managing public
health emergencies, such as the recent SARS, West Nile virus, and
monkeypox outbreaks. However, the draft report expresses caution
regarding oversight of CDC's non-emergency programmatic activities. CDC
will closely consider GAO's recommendations as the agency continues,
through the Futures Initiative, to develop and implement structural
changes to further strengthen across-the-board agency management. SARS,
West Nile virus, monkeypox, and other public health emergencies are
case studies for successful public health response - timely
intervention, coordinated across varied agencies and jurisdictions (and
even national boundaries), and real-time communication with all
stakeholders. CDC is closely examining the lessons learned from these
and other emergencies to determine the applicability to non-emergency
public health issues. CDC intends to integrate those best practices with
its successful experience in other public health domains.
The draft report states that challenges remain, and CDC agrees.
Ensuring program accountability is a significant challenge for any
government agency-one that, as stewards of the public's trust and
funding, CDC takes most seriously. CDC values GAO's insights and will
consider them in the ongoing evaluation of its organizational
structure. Like the Institute Directors of the National Institutes of
Health, CDC's Center Directors are national and international
scientific and public health leaders who are experts in their area of
responsibility and are empowered by CDC top management to direct their
programs. While some added formal reporting systems, as suggested by
GAO, maybe considered, CDC is committed to following the President's
Management Agenda (PMA) concepts, including management that focuses on
results and operational flexibility. CDC recognizes that continued
oversight from the Director's office is critical to ensure high quality
management practices and scientific excellence.
The CDC Director's two deputies are constantly engaged in the varied
science and program service issues confronted by the Centers/
Institutes/Offices (CIOs) - and thus the deputies play an integral role
in program oversight. The Chief Operating Officer, the Chief of Staff,
and the Senior Advisor for Strategy and Innovation not only have public
health program experience at both the State and CDC level, adding
practical experience and strength to OD oversight of programs, but also
possess management credentials and experience. In addition, CDC has
taken several steps to enhance systems for program oversight, creating
the Executive Leadership Team, the Management Council, and instituting
regular Cross-talks and Emerging Issues briefings between the CDC
Director and CIO Directors and staff to surface issues that require OD
oversight and involvement.
GAO noted that essential planning tools that will update CDC's
priorities and address human capital challenges are under development.
After more than a decade, CDC has embarked on a strategic planning
effort, entitled the Futures Initiative, to ensure that the agency
remains an effective, proactive public health organization, best
equipped, staffed, and managed to serve the public in the 21st century.
GAO also noted that CDC had postponed its human capital plan. Agencies
of the federal government are subject to the PMA, and CDC has briefly
postponed implementing steps for the human capital plan to refocus key
elements with the PMA - and especially to follow the recommended
premise that strategy development must precede structure and human
capital development. Since resource allocation decisions should be
based on strategic direction, CDC concluded it would be more efficient
to clarify the agency's strategies and priorities before completing an
agency-wide human capital plan. CDC agrees, however, that the human
capital plan should be completed in the near future.
Some human capital preparatory steps have occurred. Recognizing the
need to merge human capital planning efforts with the Futures
Initiative planning, in October 2003, CDC established the position of
Chief Learning Officer. This senior position will address essential
human capital development to assure that CDC staff continue to be
properly trained and positioned to carry out the agency's mission. CDC
continues to develop a range of career assistance actions that address
human capital improvement. CDC is also implementing other human capital
workforce improvements including direct hire authority, Voluntary
Separation Incentive Pay, and Voluntary Early Retirement Authority. In
the near future, CDC expects to complete a framework for its Leadership
Succession Management Plan, which will guarantee that tomorrow's
leaders are prepared to manage the important scientific and prevention
programs of CDC. As GAO noted, such changes can take years to finalize,
and CDC is taking rational, sequential leadership actions to make
certain that efficient, effective, and coordinated strategic planning
and human capital outcomes are realized.
The management and oversight of agency programs have helped CDC to
maintain its outstanding national and international reputation and
respect. The report praises CDC for establishing a Chief Operating
Officer position with clear oversight for the agency's operating units.
The report further recognizes steps CDC is taking to develop a new
management structure designed to provide a new approach to managing the
agency's public health work. The GAO draft report compliments CDC for
upgrading the agency's
response to emergencies and recognizes CDC's critical, ongoing role in
emergency response. GAO also highlights CDC's positive actions to
manage emergencies strategically. Finally, and a key factor, GAO
acknowledges that significant change can require several years, and CDC
is in the early stages of a multi-year process of change.
Specific Comments:
GAO Recommendation:
Realign and clarify oversight responsibility for the centers'
programmatic work at a level below the Director, including clarifying
the roles of OD's deputy directors.
Agency Comment:
CDC agrees that proper oversight is vital to an effectively run
organization and will evaluate this recommendation in light of the
management changes the agency has already undertaken. As mentioned
previously, CDC's CIO Directors are world-renowned scientists and
leaders, with many years of experience in their respective fields.
Given their expertise, CDC's Director holds them accountable for
results, and adheres to the PMA requirement of streamlined management.
The scientific and public health expertise of the Deputy Directors
allows them to provide guidance to the CIO Directors and to monitor
agency programs without adding another management layer to the agency's
organizational structure. The Deputy Directors have functional and
topical areas of responsibility that help maintain programmatic
direction and clarity.
GAO Recommendation:
Ensure that reporting requirements and tracking systems are developed
for OD to routinely monitor the centers' operations and programmatic
activities.
Agency Comment:
The agency's leadership recognizes that reporting and monitoring
systems are essential to effectively manage large organizations with
complex domestic and international operations. CDC is working to
institute formal reporting requirements and tracking systems that
monitor CIO activities with a special emphasis on program outputs,
outcomes, and impacts. Under the leadership of the Chief Operating
Officer, the Management Council will also provide oversight for
tracking mechanisms which will cover a range of internal business
services and systems, including budget formulation and execution,
workforce development and management, facilities management and
security, information technology management, and management of grants
and contracts.
GAO Recommendation:
Develop incentives to foster center collaboration as a standard agency
practice.
Agency Comment:
CDC continues to seek ways to strengthen inter-CIO collaboration. CDC
has made cross-CIO collaboration a key priority of the Futures
Initiative. Enhanced collaboration between and among CIOs - and with
outside partners - will further improve public:
health. CDC has already taken steps to bolster cross-CIO collaboration
by establishing the Executive Leadership Team, the Management Council,
and the regularly scheduled programmatic Cross-talks; launching the
"CDC Connects" employee information portal to promote shared goals
across the agency; developing various cross-cutting initiatives;
creating cross-functional or "matrixed" teams; and other actions.
GAO Recommendation:
Ensure that the agency's new strategic planning process will involve
CDC employees and external partners to identify agency-wide priorities,
align resources with these priorities, and facilitate the coordination
of the centers' mission-related activities.
Agency Comment:
CDC agrees with this recommendation. Since its inception, the Futures
Initiative has engaged CDC employees and external partners in critical
discussions about the agency's future. A survey sent to all CDC
employees, regular All-Hands meetings with staff, and other major
internal efforts have solicited in-the-trenches perspectives and
provided forums for employees' discussion and feedback. External
interviews and focus groups with approximately 500 customers -
including the public, business leaders, public health practitioners,
and health care providers - have offered critical insights into the
needs and priorities of those CDC serves.
GAO Recommendation:
Ensure that the agency's human capital planning efforts receive
appropriate leadership attention; this would include resuming human
capital planning, linking these efforts to the agency's strategic plan,
and linking senior executives' performance contracts with the strategic
plan.
Agency Comment:
CDC concurs that human capital planning is critically important and
merits the attention of senior leaders. CDC briefly postponed some
human capital planning to allow the Futures Initiative to proceed
logically; however, CDC has also undertaken appropriate interim
actions, such as creating the senior management position of Chief
Learning Officer to guide human capital development. CDC will link
human capital planning and deployment to the agency's strategic plan,
and appropriately connect the performance contracts of senior
executives with the developing strategic plan.
[End of section]
FOOTNOTES
[1] "Centers" refers collectively to the agency's centers, institute,
and program offices.
[2] U.S. Department of Health and Human Services, Office of Inspector
General, Audit of Costs Charged to the Chronic Fatigue Syndrome Program
at the Centers for Disease Control and Prevention, A-04-98-04226
(Washington, D.C.: May 10, 1999).
[3] U.S. General Accounting Office, Centers for Disease Control and
Prevention: Independent Accountants Identify Financial Management
Weaknesses, GAO-01-40 (Washington, D.C.: Nov. 15, 2000).
[4] U.S. General Accounting Office, West Nile Virus Outbreak: Lessons
for Public Health Preparedness, GAO/HEHS-00-180 (Washington, D.C.:
Sept. 11, 2000).
[5] U.S. General Accounting Office, Homeland Security: CDC's Oversight
of the Select Agent Program, GAO-03-315R (Washington, D.C.: Nov. 22,
2002).
[6] U.S. General Accounting Office, Results-Oriented Cultures:
Implementation Steps to Assist Mergers and Organizational
Transformations, GAO-03-669 (Washington, D.C.: July 2, 2003).
[7] In addition to CDC, there are seven Public Health Service Operating
Divisions within HHS: Agency for Healthcare Research and Quality,
Agency for Toxic Substances and Disease Registry, Food and Drug
Administration, Health Resources and Services Administration, Indian
Health Service, National Institutes of Health, and Substance Abuse and
Mental Health Services Administration.
[8] A cooperative agreement is a financial assistance instrument for
which the recipient receives money as well as programmatic
collaboration in carrying out the contemplated project or activity.
[9] The U.S. Public Health Service Commissioned Corps is one of the
seven Uniformed Services of the United States.
[10] Pub. L. No. 96-510, 94 Stat. 2767, 2778. (This act established the
Superfund program to clean up highly contaminated hazardous waste
sites.)
[11] U.S. General Accounting Office, Highlights of a GAO Roundtable:
The Chief Operating Officer Concept: A Potential Strategy to Address
Federal Governance Challenges, GAO-03-192SP (Washington, D.C.: Oct. 4,
2002).
[12] U.S. General Accounting Office, Results-Oriented Government:
Shaping the Government to Meet 21st Century Challenges, GAO-03-1168T
(Washington, D.C.: Sept. 17, 2003).
[13] This office serves as the focal point for review and clearance of
documents that require the signature of the Director and documents that
require the signature of department officials.
[14] This office performs numerous functions, including producing the
agency's annual performance reports.
[15] At that time, infectious disease outbreaks were handled outside of
the emergency operations centers.
[16] U.S. General Accounting Office, Bioterrorism: Public Health
Response to Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.:
Oct. 15, 2003).
[17] This process is also used to manage nonemergency issues received
from external sources, such as the Congress, HHS, and the media.
[18] U.S. General Accounting Office, Emerging Infectious Diseases:
Consensus on Needed Laboratory Capacity Could Strengthen Surveillance,
GAO/HEHS-99-26 (Washington, D.C.: Feb. 5, 1999).
[19] U.S. General Accounting Office, A Model of Strategic Human Capital
Management, GAO-02-373SP (Washington, D.C.: Mar. 15, 2002), and Human
Capital: Key Principles From Nine Private Sector Organizations, GAO/
GGD-00-28 (Washington, D.C.: Jan. 31, 2000).
[20] The administration's management priorities are specified in the
President's Management Agenda, which addresses executive branch
management practices in the areas of human capital, competitive
sourcing, financial performance, electronic government, and the
integration of budget and performance.
[21] Healthy People 2010 is a national health promotion and disease
prevention initiative that aims to improve the health of all Americans,
eliminate disparities in health, and improve years and quality of life.
These goals and objectives were launched by HHS and the Office of the
Surgeon General.
[22] U.S. General Accounting Office, Results-Oriented Cultures: Using
Balanced Expectations to Manage Senior Executive Performance,
GAO-02-966 (Washington, D.C.: Sept. 27, 2002).
[23] U.S. General Accounting Office, Human Capital: Insights for U.S.
Agencies from Other Countries' Succession Planning and Management
Initiatives, GAO-03-914 (Washington, D.C.: Sept. 15, 2003).
[24] Senior managers and supervisors were defined as positions at GS-14
or higher--or the equivalent thereof. However, these data did not
include officials of the Public Health Service Commissioned Corps, who
are eligible to retire at 20 years of service and who must retire after
30 years of service.
[25] CDC's personnel data show that staff who are eligible to retire
tend to stay at the agency an average of about 3 years beyond their
eligibility dates.
[26] Other attrition was due to reasons such as death, termination of
limited appointments, and separation.
[27] OD officials told us that some OD offices and centers give
employees the choice to participate in exit interviews. However, the
offices and centers use different methods in conducting these
interviews.
[28] U.S. General Accounting Office, Human Capital: Key Principles for
Effective Strategic Workforce Planning, GAO-04-39 (Washington, D.C.:
Dec. 11, 2003).
[29] U.S. General Accounting Office, Human Capital: Selected Agency
Actions to Integrate Human Capital Approaches to Attain Mission
Results, GAO-03-446 (Washington, D.C.: Apr. 11, 2003).
[30] CDC officials told us that some items of a sensitive nature were
removed from the calendar before it was given to us.
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