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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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