Centers for Disease Control and Prevention: Agency Leadership Taking Steps to Improve Management and Planning, but Challenges Remain
Published: 2004-01-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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.  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. 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. 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. 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.
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. 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.)
subsections: section_title: Background
paragraphs: 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. 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.)
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. 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. 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.
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.
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.  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.
section_title: Despite the Merit of Some Changes, CDC’s Executive Structure Is Not Well Aligned to Oversee Centers’ Programmatic Work
paragraphs: 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.
subsections: section_title: OD’s Structure for Overseeing Centers’ Programmatic Work Raises Concerns
paragraphs: 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.)
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. It  also parallels the experience of successful organizations that place this  type of management position among the agency’s top leadership.
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 and  the Office of Program Planning and Evaluation.
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.)
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.
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.
section_title: Unclear Roles and Responsibilities of OD Deputy Positions Slow Intention to Integrate Center Activities around Themes
paragraphs: 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.)
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.
section_title: OD Has Improved Oversight of Public Health Emergencies, but Concerns Remain about Oversight of Ongoing Agency Activities
paragraphs: 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.
subsections: section_title: OD Has Improved Its Ability to Oversee the Agency’s Response to Public Health Emergencies
paragraphs: 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. 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.
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.
section_title: OD Faces Challenges in Overseeing Nonemergency Public Health Work
paragraphs: 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.
subsections: section_title: Few Tracking Systems Are in Place to Provide Management Oversight Information
paragraphs: 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. 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.
section_title: OD Efforts to Foster Collaboration among Centers Are Incomplete
paragraphs: 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. 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.
section_title: Planning Tools That OD Needs to Manage Agency Priorities and Human Capital Challenges Are Not Yet Operational
paragraphs: 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.
subsections: section_title: OD’s Priority-Setting Efforts Have Lacked a Long-Term Focus
paragraphs: 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.  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.
section_title: Strategic Planning Process Recently Initiated
paragraphs: 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.  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.
section_title: Human Capital Plan Initiated but Recently Suspended
paragraphs: 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. 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. Thus,  within several years, the agency could potentially lose a key portion of its  human capital that possesses both managerial and technical expertise.
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), CDC  does not systematically document the reasons for resignations, either  through standard “exit interviews” of employees who leave the agency or  some other means. 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.
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. 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.
section_title: Conclusions
paragraphs: 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.
section_title: Recommendations for Executive Action
paragraphs: 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.
section_title: Agency Comments
paragraphs: 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.
section_title: Appendix I: Scope and Methodology
paragraphs: 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.
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.
section_title: Appendix II: Comments from the Centers for Disease Control and Prevention