In 2000, significantly fewer managers at CMS—then known as the Health Care Financing Administration—reported using performance information for various management decisions, as compared to their counterparts in the rest of government. Between our 2000 and 2007 surveys, however, CMS showed one of the largest average increases in the percentage of managers who reported using performance information for certain decisions. This increase placed CMS in about the middle of our agency rankings, which were based on an index of 2007 survey results designed to reflect the extent to which managers at each agency reported using performance information. Our analysis of CMS survey results, management interviews, and agency policies, performance reports, and other relevant documents indicated that the adoption of key management practices contributed to this improvement. Our 2007 survey results showed that significantly more CMS managers agreed that their leadership is committed to achieving results, than they did in 2000 (see fig. 2). Nearly all of the CMS officials we interviewed credited the commitment of one or more agency leaders—such as the CMS Administrator or the Chief Operating Officer—for their increased use of performance information to achieve results. One way in which leaders can demonstrate their commitment is through frequent communication of established goals and progress made toward those goals. As an example, in an effort to reduce the incidence of pressure ulcers among nursing home residents, a Region IV manager described to us how regional leadership began to routinely share performance information about the pressure-ulcer problem with the many stakeholders involved with patient care including hospital and nursing-home personnel, patient advocates, emergency medical technicians, and others. CMS contracts with states to assess the quality of care provided by Medicare and Medicaid-participating facilities, such as nursing homes, and is therefore several steps removed from the delivery of health-care services to patients and the resulting health outcomes. According to CMS Region IV managers we interviewed, this indirect influence had been considered a limiting factor in CMS’ ability to affect outcomes among nursing-home patients. However, these same managers said that leadership commitment to getting stakeholders to the table and sharing performance information with them were critical factors in bringing about a reduction in the incidence of pressure ulcers. In that region, between fiscal years 2006 and 2008, this improvement translated into nearly 2,500 fewer long-stay nursing-home residents with pressure ulcers. Our survey results also indicated that between 2000 and 2007, a significantly greater percentage of CMS managers reported that they were held accountable for program results (see fig. 3). In 2006, as part of a change throughout HHS, the agency adopted a new performance-management system that links organizational and program goals with individual accountability for program results. Top CMS headquarters officials said that the new system had made individual accountability for program results more explicit. They described how agency goals and objectives were embedded in the Administrator’s performance agreement and cascaded down through the management hierarchy, so that each level of management understood their accountability for achieving the broad department and agency-level goals. To illustrate, broad goals for preventive healthcare cascade from HHS through a CMS director responsible for increasing early detection of breast cancer among Medicare beneficiaries, to a CMS Health Insurance Specialist responsible for communications to raise awareness of the importance of mammograms and other preventive measures. Our survey results show that between 2000 and 2007, there was a significant decline in the percentage of CMS managers who reported that difficulty developing meaningful measures was a hindrance to using performance information (see fig. 4). According to CMS officials, to ensure that performance information was useful to managers, they limited the number of measures for GPRA reporting purposes to the 31 that represented the agency’s priorities. This official noted that it would be unmanageable to measure and report on every aspect of their programs and processes. They ultimately settled on a set of performance goals that helped managers and staff identify performance gaps and opportunities to improve performance to close the gaps. Our survey results and interviews with several CMS officials indicate that the agency also took steps to develop their staff’s capacity to use performance information, such as investing in improved data systems and offering increased training opportunities on a range of topics related to performance planning and management. Between 2000 and 2007, there was a significant positive increase on all six survey questions related to managers’ access to training over the past three years on the use of performance information for various activities (see fig. 5). According to one official we spoke with, increasing her staff’s skills in conducting analyses of performance information and presenting findings was a gradual process that required training, coaching, and guidance. Just as the adoption of key management practices can facilitate greater use of information and a greater focus on results, the absence of these practices can hinder widespread use. Fewer managers at FEMA and Interior reported making extensive use of performance information for decision making compared to managers at other agencies. Survey results, interviews with senior level-officials and regional and program managers, and a review of policies and other documents related to performance planning and management at both agencies showed that inconsistent use of these practices contributed to this condition. Our 2007 survey results indicated that, compared to the rest of government, a smaller percentage of FEMA managers agreed their top leadership demonstrated a strong commitment to using performance information to guide decision making (see fig. 6). Our interviews with officials at FEMA were consistent with these survey results, indicating that management commitment was demonstrated inconsistently across the program directorates and regions we reviewed. Leaders and managers we spoke to throughout the management hierarchy were clearly committed to carrying out FEMA’s mission. The level of commitment to using performance information for decision making, however, appeared to vary among those we interviewed. For example, in the Disaster Assistance Directorate, one headquarters official told us that he does not need performance targets to help him determine whether his directorate is accomplishing its mission, relying instead on verbal communications with the leadership and with FEMA’s regions, joint field offices, and members of Congress to identify issues to be addressed and areas that are running well. Another headquarters official within the Disaster Assistance Directorate’s Public Assistance program said he does not receive formal performance reports from regional program managers, nor are any performance reports required of him by his supervisors; rather, he said that he spoke to the regions on an ad hoc basis as performance problems arose. These officials expressed reluctance toward holding their staff accountable for meeting performance goals due to external factors, such as the unpredictability of disasters beyond their control. Further, they expressed uncertainty as to how they could use performance information in the face of uncontrollable external factors. As noted below, however, other managers in FEMA have found ways to take unpredictable occurrences into account as they monitor their progress in achieving performance goals. FEMA faces other hurdles, including the lack of a performance- management system requiring managers to align agency goals with individual performance objectives, which makes it challenging for managers to hold individuals accountable for achieving results. The agency also lacks adequate information systems for ensuring that performance information can be easily collected, communicated, and analyzed. For example, in order to gather performance information across directorates, one official reported that it was necessary to write programs to generate specific reports for each of the systems and then manually integrate the information, making it difficult to produce repeatable and verifiable reports. Further, according to several officials we interviewed, there was a limited number of staff with the analytic skills necessary to work with performance metrics. As with FEMA, at Interior we observed that leaders and managers at all levels conveyed a strong commitment to accomplishing the agency’s mission. Interior’s survey results were similar to FEMA’s results on items related to managers’ perceptions of their leadership’s commitment to using performance information. Interior’s 2007 results were also lower than those in the rest of government (see fig. 7). According to officials we interviewed, leaders at Interior and NPS did not effectively communicate to their staff how, if at all, they used performance information to identify performance gaps and develop strategies to better achieve results. Several NPS managers referred to the performance reporting process as “feeding the beast,” because they receive little or no communication from either Interior or NPS headquarters in response to the information they are required to report, leading them to assume that no one with authority reviews or acts on this information. Furthermore, some bureau-level managers at NPS and Reclamation said the performance measures they are required to report on were not always useful for their decision making, either because there were too many or because they were not credible. We have previously reported that to be useful and meaningful to managers and staff across an agency, performance measures should be limited at each organizational level to the vital few that provide critical insight into the agency’s core mission and operations. However, in the seven years since the inception of the former administration’s Performance Assessment Rating Tool (PART) initiative, Interior has expanded its performance reporting to include 440 PART program measures, in addition to the approximately 200 strategic performance measures used to track progress against its strategic and annual plans, as required by GRPA. A senior headquarters official at Interior said that the number of measures makes it difficult for senior leaders and managers to focus on priorities and easily identify performance gaps among the different program areas. At NPS alone, managers were required to report on 122 performance measures related to GPRA and PART. Managers at both NPS and Reclamation also described performance information that lacked credibility because the measures either did not accurately define comparable elements or did not take into account different standards across bureaus or units. For example, several NPS managers noted that one of the measures on which they report, “percent of historic structures in good condition,” does not differentiate between a large, culturally significant structure such as the Washington Monument and a smaller, less significant structure such as a group of headstones. Consequently, a manager could achieve a higher percentage by concentrating on improving the conditions of numerous less significant properties. Poorly integrated performance and management information systems further hindered NPS and Reclamation managers’ efforts to use performance information to inform their decision making.