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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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.