Centers for Disease Control and Prevention: Agency Leadership	 
Taking Steps to Improve Management and Planning, but Challenges  
Remain (30-JAN-04, GAO-04-219). 				 
                                                                 
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.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-219 					        
    ACCNO:   A09181						        
  TITLE:     Centers for Disease Control and Prevention: Agency       
Leadership Taking Steps to Improve Management and Planning, but  
Challenges Remain						 
     DATE:   01/30/2004 
  SUBJECT:   Agency missions					 
	     Federal agency reorganization			 
	     Human resources utilization			 
	     Internal controls					 
	     Performance measures				 
	     Prioritizing					 
	     Public Health Service facilities			 
	     Strategic planning 				 

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GAO-04-219

United States General Accounting Office

GAO

Report to the Director of the Centers for

                         Disease Control and Prevention

January 2004

CENTERS FOR DISEASE CONTROL AND PREVENTION

     Agency Leadership Taking Steps to Improve Management and Planning, but
                               Challenges Remain

                                       a

GAO-04-219

Highlights of GAO-04-219, a report to the Director of the Centers for
Disease Control and Prevention

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.

GAO recommends that the CDC Director ensure OD's oversight of the centers'
programmatic work at a level below the Director, improve OD's monitoring
of the centers' operations and programmatic activities, and ensure that
the agency's strategic and human capital planning are coordinated and done
expeditiously. CDC responded with a series of actions to address these
recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-04-219.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marjorie E. Kanof at (202)
512-7101.

January 2004

CENTERS FOR DISEASE CONTROL AND PREVENTION

Agency Leadership Taking Steps to Improve Management and Planning, but
Challenges Remain

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.

Contents

  Letter

Results in Brief
Background
Despite the Merit of Some Changes, CDC's Executive Structure Is

Not Well Aligned to Oversee Centers' Programmatic Work OD Has Improved
Oversight of Public Health Emergencies, but Concerns Remain about
Oversight of Ongoing Agency Activities Planning Tools That OD Needs to
Manage Agency Priorities and

Human Capital Challenges Are Not Yet Operational Conclusions
Recommendations for Executive Action Agency Comments

                                       1

                                      3 5

10

18

23 28 29 30

Appendix I Scope and Methodology

Appendix II 	Comments from the Centers for Disease Control and Prevention

  Table

Table 1: OD's Organizational Themes and Corresponding OD Management
Positions

  Figures

Figure 1: CDC's Funding and FTE Growth from Fiscal Years 1946 to 2003 6
Figure 2: Principal Locations of CDC Employees within the United

States 8 Figure 3: CDC Organization Chart as of November 1, 2003 9 Figure
4: OD Management Team Below the Director as of

November 1, 2003 12 Figure 5: Senior Officials Reporting to CDC's Director
as of November 1, 2003 15 Figure 6: Timeline of High-Profile Public Health
Events and Emergencies Requiring CDC Response 16

Abbreviations

ATSDR Agency for Toxic Substances and Disease Registry
CDC Centers for Disease Control and Prevention
COO Chief Operating Officer
FTE full-time equivalent
GPRA Government Performance and Results Act of 1993
HHS Department of Health and Human Services
NCEH National Center for Environmental Health
OD Office of the Director
OTPER Office of Terrorism Preparedness and Emergency Response
SARS severe acute respiratory syndrome

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separately.

United States General Accounting Office Washington, DC 20548

January 30, 2004

The Honorable Julie L. Gerberding, MD, MPH Director, Centers for Disease
Control and Prevention

Dear Dr. Gerberding:

As the national focal point for conducting disease prevention and control
efforts, the Centers for Disease Control and Prevention (CDC) is widely
recognized for its work in investigating disease outbreaks as well as its
health promotion programs. Since it was established in 1946, CDC's scope
of work has evolved from a narrow focus on malaria control and other
communicable diseases to a wide and complex range of public health
responsibilities. Today, CDC's mission is "to promote health and quality
of life by preventing and controlling disease, injury, and disability."
Establishing and maintaining balance within this broad mission is an
ongoing challenge for agency management. CDC, an agency in the Department
of Health and Human Services (HHS), has the lead federal role in
responding to infectious disease outbreaks, such as severe acute
respiratory syndrome (SARS), monkeypox, and the West Nile virus. The
agency is also responsible for addressing nonemergency public health
concerns, such as chronic diseases (including heart disease, cancer, and
diabetes), childhood immunizations, and environmental and occupational
health matters.

CDC's agency management responsibilities are considerable. In fiscal year
2003, CDC managed a budget of almost $7 billion and its full-time
equivalent (FTE) staff numbered more than 8,800. Most of the agency's
staff are distributed across 11 centers, which are located at multiple
sites.1 The centers are responsible for working with the agency's external
partners-which include state, local, and international public health
agencies, among others-to carry out a range of public health activities.
In addition, CDC's Director serves as the administrator of HHS's Agency
for Toxic Substances and Disease Registry (ATSDR), which focuses on
environmental health-related issues. CDC's top office, the Office of the
Director (OD), has overall management responsibility for CDC and ATSDR.

1"Centers" refers collectively to the agency's centers, institute, and
program offices.

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.2 In 2000, we reported that CDC's
financial management capabilities had not kept pace with the agency's
expanded mission and increased funding and that financial management was
not a high priority relative to the agency's other functions.3 That same
year, after the public health community's response to the first outbreak
of the West Nile virus, we reported that public health preparedness could
be improved, in part, through better communication among public health
agencies, including CDC.4 During the 2001 anthrax incidents, the agency
garnered criticism for its slow release of important information. In 2002,
we subsequently reported internal management control weaknesses with CDC's
oversight of the Select Agent Program, which is responsible for regulating
the transfer of certain biological agents and toxins-such as anthrax-to
appropriate laboratories.5

In the wake of the anthrax incidents and SARS outbreak, CDC has emerged as
a key player in preparing the nation for public health emergencies. In
2002, the agency's OD spearheaded a number of initiatives aimed at
organizational change. Such change is necessarily a long-term undertaking,
requiring leadership and commitment. Experience shows that successful
major change management initiatives in large private and public sector
organizations can often take at least 5 to 7 years. This length of time
and the frequent turnover of political leadership in the federal
government have often made it difficult to obtain the sustained and

2U.S. Department of Health and Human Services, Office of Inspector
General, Audit of Costs Charged to the Chronic Fatigue Syndrome Program at
the Centers for Disease Control and Prevention, A-04-98-04226 (Washington,
D.C.: May 10, 1999).

3U.S. General Accounting Office, Centers for Disease Control and
Prevention: Independent Accountants Identify Financial Management
Weaknesses, GAO-01-40 (Washington, D.C.: Nov. 15, 2000).

4U.S. General Accounting Office, West Nile Virus Outbreak: Lessons for
Public Health Preparedness, GAO/HEHS-00-180 (Washington, D.C.: Sept. 11,
2000).

5U.S. General Accounting Office, Homeland Security: CDC's Oversight of the
Select Agent Program, GAO-03-315R (Washington, D.C.: Nov. 22, 2002).

inspired attention to make needed changes.6 At this time, OD's structural
and management changes are relatively new. This report examines the extent
to which these changes have helped balance OD's oversight of the agency's
emergent and ongoing public health responsibilities. Specifically, it
examines OD's (1) executive management structure, (2) approach to
overseeing the agency's work, and (3) approach to setting the agency's
priorities.

In performing our review, we interviewed CDC senior executives within OD.
We also met with senior managers responsible for agency operations and
selected senior managers in six of the agency's centers and ATSDR. We
analyzed pertinent agency documents and interviewed officials at state and
local health departments, health-care-related associations, nonprofit
organizations, private industry, and schools of public health. We
performed our work from June 2002 through January 2004 in accordance with
generally accepted government auditing standards. (See app. I for further
detail.)

The management team in CDC's top office-OD-is undergoing a structural
change designed to provide a new approach to managing the agency's public
health work. Through this effort, CDC has taken steps that have merit. For
example, OD established a Chief Operating Officer (COO) position with
clear oversight authority for the agency's operations units, such as
financial management and information technology. However, a significant
oversight weakness remains: no similar position or combination of
positions on OD's management team below the Director's level has been
established to oversee the programs and activities of the centers, which
perform the bulk of the agency's public health work. Only CDC's Director
has line authority for the centers, and the extraordinary demands on the
Director's time associated with public health emergencies and other
external events make the practicality of this oversight arrangement
uncertain. Another of OD's structural initiatives was to align OD
management team positions with five broad mission "themes," or goals, that
cut across the institutional boundaries of the centers. The intent was to
foster among CDC's 11 independent centers a more integrated approach to
performing the agency's mission. This purpose may

  Results in Brief

6U.S. General Accounting Office, Results-Oriented Cultures: Implementation
Steps to Assist Mergers and Organizational Transformations, GAO-03-669
(Washington, D.C.: July 2, 2003).

be difficult to realize, however, as connections between certain themes
and associated OD positions are not sufficiently clear.

OD has made significant improvements in directing the agency's response to
public health emergencies, but concerns remain about OD's oversight of
nonemergency public health work. An emergency preparedness and response
office was created in OD that, during the SARS outbreak, successfully
coordinated the response efforts of CDC's various centers and OD staff
offices. OD's communications office also developed an emergency
communication system that facilitates coordination among specialists
agencywide so that they can act in concert during public health
emergencies. However, OD continues to face challenges in monitoring the
agency's ongoing programmatic activities. Historically, OD has operated in
an environment in which-outside of routine management meetings-its
communication with center management officials was largely informal and
relied substantially on personal relationships. Currently, OD's efforts to
monitor the centers are still not sufficiently systematic. For example,
few formal systems are in place to track the status of centers' activities
and develop strategies to mitigate adverse consequences in the event that
some activities fall behind schedule. Although OD has a process for center
officials to elevate important issues, the information flow under this
process is largely center-driven, as the subjects discussed are typically
raised at the discretion of the center officials. OD has not established
its own criteria specifying the type of matters warranting management
input or the time frames for reporting such matters. Similarly, OD's
efforts to foster coordination among the centers as a standard agency
practice for nonemergency public health work fall short of
institutionalizing such collaboration.

The planning tools that OD needs to set agency priorities, including
addressing human capital challenges, are under development. In recent
years, OD has operated without an up-to-date agencywide planning strategy
with which to set mission priorities and unify the work of CDC's various
centers. In June 2003, OD initiated an agencywide strategic planning
process. In a separate planning effort initiated in April 2003, CDC began
developing a human capital plan for meeting the agency's current and
future staffing needs. This effort has been suspended while the strategic
planning process gets under way, and no time frames have been established
for resuming its development. At the same time, agency attrition and
future limits on workforce growth suggest that agency leadership may be
needed to ensure that workforce planning occurs expeditiously.

Background

In light of OD's management challenges, we are making several
recommendations to the CDC Director. These include ensuring OD's oversight
of the centers' programmatic work at a level below the Director, improving
OD's monitoring of the centers' operations and programmatic activities,
and ensuring that the agency's strategic and human capital planning are
coordinated and done expeditiously. In commenting on a draft of this
report, CDC listed a series of actions it would take for each
recommendation, such as evaluating OD's oversight structure, instituting
formal reporting requirements and tracking systems, and linking human
capital planning and deployment with the agency's strategic plan.

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.7 CDC serves as the national focal point for developing and
applying disease prevention and control, environmental health, and health
promotion and education activities designed to improve the health of
Americans. CDC is also responsible for leading national efforts to detect,
respond to, and prevent illnesses and injuries that result from the
release of biological, chemical, or radiological agents.

CDC was originally established in 1946 as the Communicable Disease Center
with the mission to help state and local health officials in the fight
against malaria, typhus, and other communicable diseases. Over the years,
CDC's mission and scope of work have continued to expand in concert with
public health needs. Commensurate with its increased scope of work, CDC's
budget and staff have grown. In 1946, the agency had a budget of about $1
million and had over 360 FTEs. In fiscal year 2003, CDC managed a budget
of almost $7 billion and had over 8,800 FTEs. (See fig. 1.)

7In addition to CDC, there are seven Public Health Service Operating
Divisions within HHS: Agency for Healthcare Research and Quality, Agency
for Toxic Substances and Disease Registry, Food and Drug Administration,
Health Resources and Services Administration, Indian Health Service,
National Institutes of Health, and Substance Abuse and Mental Health
Services Administration.

Figure 1: CDC's Funding and FTE Growth from Fiscal Years 1946 to 2003

Funding in 2003 dollars (thousands)a

$8,000,000

$7,000,000

$6,000,000

$5,000,000

$4,000,000

$3,000,000

$2,000,000

$1,000,000

0 1946 1950 1960b 1970 1980 1990 2000 2003

                                  Fiscal year

FTEs
Funding (2003 dollars)
Source: CDC.

Note: GAO analysis of CDC data.

                                   FTEs 9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0

aWe adjusted each of the budget numbers using a chain-type Gross Domestic
Product Price Index and an estimate for 2003 provided by the Congressional
Budget Office because fiscal year 2003 had not ended at the time these
calculations were made.

bFTE data are for 1961.

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.8
The majority of these funds-about 75 percent-were disbursed to state
health departments. The remaining 25 percent of these funds were disbursed
to various other public and private entities.

CDC's workforce consists of 170 job occupations including physicians,
statisticians, epidemiologists, laboratory experts, behavioral scientists,
and health communicators. Seventy-eight percent of CDC's workforce
consists of permanent civil service staff. U.S. Public Health Service
Commissioned Corps employees account for 10 percent of the workforce, and
temporary employees make up the remaining 12 percent.9 Most of CDC's staff
are dispersed across over 30 locations in Atlanta, Georgia. CDC also has
more than 2,000 employees at other locations in the United States. (See
fig. 2.) Additional CDC staff are deployed to more than 37 foreign
countries, assigned to 47 state health departments, and dispersed to
numerous local health agencies on both short- and long-term assignments.

8A cooperative agreement is a financial assistance instrument for which
the recipient receives money as well as programmatic collaboration in
carrying out the contemplated project or activity.

9The U.S. Public Health Service Commissioned Corps is one of the seven
Uniformed Services of the United States.

Figure 3: CDC Organization Chart as of November 1, 2003

Source: CDC.

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

  Despite the Merit of Some Changes, CDC's Executive Structure Is Not Well
  Aligned to Oversee Centers' Programmatic Work

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 1980.10 ATSDR
works to prevent exposures to hazardous wastes and environmental spills of
hazardous substances. Headquartered in Atlanta, the agency has 10 regional
offices and an office in Washington, D.C. It also has a multidisciplinary
staff of about 400 employees. For many years, ATSDR has worked closely
with CDC's National Center for Environmental Health (NCEH), which is
responsible for providing national leadership in preventing and
controlling disease associated with environmental causes. To foster
greater efficiency, NCEH and ATSDR signed a statement of intent in January
2003 to consolidate their administrative and management functions for
financial savings. In August 2003, CDC's OD announced HHS's approval for a
single director to lead both ATSDR and NCEH. Final approval of this
consolidation effort was completed on December 16, 2003.

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.

10Pub. L. No. 96-510, 94 Stat. 2767, 2778. (This act established the
Superfund program to clean up highly contaminated hazardous waste sites.)

    OD's Structure for Overseeing Centers' Programmatic Work Raises Concerns

In January 2003, as part of the agency's transformation efforts, CDC's
Director announced an OD management team consisting of five senior
officials, including a COO, two deputies, a senior advisor, and a Chief of
Staff. A beneficial change in OD's structure was the creation of a COO
with clear oversight authority over the agency's operations units,
positioning OD to oversee these areas appropriately. However, no similar
position or combination of positions has been established in OD to oversee
the programs and activities of the centers, as no one below the Director
on OD's management team has direct line authority for the centers'
programmatic work. This also holds true for the three officials added to
the OD management team as of fall 2003-the Director of the CDC Washington
Office, the Senior Advisor to the Director, and the Associate Director for
Terrorism Preparedness and Response. (See fig. 4.)

Figure 4: OD Management Team Below the Director as of November 1, 2003

Source: CDC.

Note: GAO analysis of CDC data.

aStaff reporting to the COO, who heads the office, include the Deputy COO,
the Chief Information Officer, and the Chief Financial Officer.

bStaff reporting to the Director of the CDC Washington Office include a
deputy director.

cStaff reporting to the Associate Director for Terrorism Preparedness and
Response include two deputy directors and an associate director.

A look at the roles of OD's management team highlights a structural
weakness in oversight authority for the centers' programmatic work.

o  	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.11 It also parallels the
experience of successful organizations that place this type of management
position among the agency's top leadership.12

o  	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.

o  	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.

o  	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
Secretariat13 and the Office of Program Planning and Evaluation.14

11U.S. General Accounting Office, Highlights of a GAO Roundtable: The
Chief Operating Officer Concept: A Potential Strategy to Address Federal
Governance Challenges, GAO-03-192SP (Washington, D.C.: Oct. 4, 2002).

12U.S. General Accounting Office, Results-Oriented Government: Shaping the
Government to Meet 21st Century Challenges, GAO-03-1168T (Washington,
D.C.: Sept. 17, 2003).

13This office serves as the focal point for review and clearance of
documents that require the signature of the Director and documents that
require the signature of department officials.

14This office performs numerous functions, including producing the
agency's annual performance reports.

o  	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.

o  	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.

o  	Associate Director for Terrorism Preparedness and Response. This
official's responsibilities include managing OD's Office of Terrorism
Preparedness and Emergency Response (OTPER) as well as CDC's national
bioterrorism program.

As of November 1, 2003, a total of 20 officials, including the 11 center
directors, reported to the CDC Director. (See fig. 5.)

Figure 5: Senior Officials Reporting to CDC's Director as of November 1,
2003

Source: CDC.

Note: GAO analysis of CDC data.

aAs of August 18, 2003, the Director of NCEH became a Senior Advisor
within OD, and the Director of ATSDR became the head of the consolidated
management and administrative structure for ATSDR and NCEH.

bAlthough this official reports to the CDC Director, the official is not a
member of the OD management team.

Whether this structural arrangement can support effective oversight of the
agency's programmatic work is uncertain, given the growth in the demands
on the CDC Director's time along with the likely change in directors over
time. Since the first West Nile virus outbreak in 1999, CDC

has responded to a steady stream of high-profile public health
emergencies, including the anthrax incidents and the more recent outbreak
of SARS. (See fig. 6.) Responding to these events has required the focused
attention of the CDC Director. In addition, routine demands on the
Director's time-such as testifying before the Congress, coordinating with
HHS officials, and meeting with other national and international public
health officials-subtract from the time the Director has to oversee the
centers, which perform the core of CDC's mission work.

Figure 6: Timeline of High-Profile Public Health Events and Emergencies
Requiring CDC Response

Note: GAO analysis of CDC data.

The typical change in politically appointed agency heads every several
years is another factor that makes center oversight solely by the Director
a management vulnerability. CDC has had four directors, including the
current one, since 1990. While there is nothing uncommon or irregular
about such change, it is significant from a management perspective, as
agency heads typically need time to acclimate to their new
responsibilities and may not stay in office long enough to
institutionalize management improvements.

    Unclear Roles and Responsibilities of OD Deputy Positions Slow Intention to
    Integrate Center Activities around Themes

Despite the restructuring of OD to reflect agency mission themes, this
effort falls short of its intention, owing to a lack of clarity and
definition in the roles of the OD deputies. CDC's Director established
five mission themes, or goals-science, strategy, service, systems, and
security. The intention was to acknowledge that shared goals cut across
the agency's diverse centers and that viewing the work in this way could
foster collaboration. The new OD structure announced in January 2003
aligned executive management positions with each of the themes. (See table
1.)

Table 1: OD's Organizational Themes and Corresponding OD Management
Positions

Themes Positions

Excellence in Science: Practice evidence-based Deputy Director for Science
and
science grounded in sound peer-reviewed Public Health
research.

Excellence in Service: Promote efficient service Deputy Director for
Public Health to meet the needs of partners and customers. Service

Excellence in Systems: Fine-tune and manage Chief Operating Officer
systems so that personnel, technology,
infrastructure, and information are used efficiently
to achieve results.

Excellence in Strategy: Ensure that strategies Senior Advisor for Strategy
and prepare agency for future challenges. Innovation

Excellence in Security: Ensure public health Associate Director for
Terrorism

a

preparedness and support response efforts. Preparedness and Response

Source: CDC.

aAlthough this position and its corresponding theme were also announced in
January 2003, this official was not a member of the OD management team
until October 2003.

The distinction between the roles of the two deputy positions-Deputy
Director for Science and Public Health and Deputy Director for Public
Health Service-has not been clearly made. The role of the Deputy Director
for Science and Public Health is to serve as OD's contact point to the
centers in areas including agency reports, guidelines and recommendations,
and outbreak investigations. However, this deputy's role is not distinct
from that of the Deputy Director for Public Health Service, who serves as
OD's liaison to public health agencies and other external partners as well
as OD's contact point for certain scientific issues, including HIV
policies, occupational safety and health policies, injury and violence
prevention policies, and programs to address public health disparities.
Addressing public health disparities, however, is the mission of CDC's
Office of Minority Health, which reports to the other deputy-the Deputy
Director for Science and Public Health. Furthermore, some center officials
said that regarding science-related issues involving CDC's external
partners, they were uncertain whether the primary point of contact should
be the Deputy Director for Science and Public Health or the Deputy
Director for Public Health Service.

  OD Has Improved Oversight of Public Health Emergencies, but Concerns Remain
  about Oversight of Ongoing Agency Activities

OD has implemented several changes in its approach to managing the
agency's response to public health emergencies, including the creation
within OD of an emergency operations office that, during the SARS
outbreak, successfully coordinated the response efforts of CDC's various
centers and staff offices. However, concerns remain about OD's management
of ongoing agency activities, as few systems are in place to provide top
agency officials with essential oversight information or to foster
collaboration among the centers.

    OD Has Improved Its Ability to Oversee the Agency's Response to Public
    Health Emergencies

In recognition of past problems, OD initiated several structural and
procedural changes that improved its ability to oversee the agency's
response to public health emergencies. Specifically, the 2001 anthrax
incidents revealed weaknesses in the agency's ability to coordinate
internal response efforts and in its efforts to communicate with the
nation's public health agencies, medical communities, and other external
partners-a problem that had also been identified during the response to
the first West Nile virus outbreak in 1999. Agency officials and external
partners recognized several problems that needed to be addressed:

o  	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.

o  	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.15 After the terrorist attacks on September 11,
2001, CDC established two additional emergency operations centers in the
National Center for Infectious Diseases and the Public Health Practice
Program Office. The internal document asserted that after the subsequent
anthrax incidents, CDC's multiple emergency

15At that time, infectious disease outbreaks were handled outside of the
emergency operations centers.

operation centers could not provide the agencywide coordinated effort
needed to address a crisis.

o  	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.16

o  	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,

16U.S. General Accounting Office, Bioterrorism: Public Health Response to
Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.: Oct. 15, 2003).

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-andcontrol focal point and eliminate the need to coordinate
efforts of multiple centers during emergencies. According to the Associate
Director for Terrorism Preparedness and Response, the emergency operations
center is operational around the clock and has a small number of dedicated
staff. In times of emergency, subject matter and communication experts
from the centers are temporarily detailed for 3 to 6 months as needed. For
example, during the SARS response, individuals from the National Center
for Infectious Diseases, the National Institute for Occupational Safety
and Health, the Epidemiology Program Office, and the Global Health Office,
among others, staffed the emergency operations center and returned to
normal duties at predetermined intervals to mitigate any major impact on
routine public health work. This logistical approach to staffing and
resources was intended to enable CDC to respond to multiple public health
emergencies, if needed.

Within OD, the Office of Communication works with OTPER to facilitate
external communications during public health emergencies. In August 2002,
this office established an emergency communication system to enhance CDC's
ability to disseminate timely and reliable information. This system
consists of 10 teams that include agency staff from various units who can
be called on to act in concert during public health emergencies. Each team
has a particular focus-such as media relations, telephone hotline
information, Web site updates, and clinician communication. In June 2003,
CDC named an Emergency Communication System Coordinator to provide
day-to-day oversight of the teams.

    OD Faces Challenges in Overseeing Nonemergency Public Health Work

Despite improvements to crisis management, OD faces challenges in managing
its nonemergency public health work. Typically, the attention of OD's top
officials has been focused on emergent public health issues, such as
infectious disease outbreaks, leaving little time for focusing on
nonemergency public health work and agency operations. OD has also
operated in an environment that until recently had not significantly
evolved from the time when the agency was smaller and its focus was
narrower; outside of routine management meetings, OD's communication with
the centers was largely informal and relied substantially on personal

Few Tracking Systems Are in Place to Provide Management Oversight
Information

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.

o  	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.

o  	In fall 2003, OD began compiling a weekly list of selected CDC
publications, correspondence, and activities.

o  	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.17 Historically, the center
directors, accustomed to operating autonomously, had little precedent for
raising issues for OD management input. In January 2003, OD instituted the
issues management process, which, among other things, sought to encourage
center officials to elevate significant matters that are not national
emergencies but that warrant timely input from the agency's senior
managers. Under this process, a center official seeking management input
on an issue of concern contacts OD's Chief of Staff, who is responsible
for coordinating agency input on the issue. The Chief of Staff identifies
the appropriate senior officials for handling the concern and

17This process is also used to manage nonemergency issues received from
external sources, such as the Congress, HHS, and the media.

OD Efforts to Foster Collaboration among Centers Are Incomplete

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 1999.18 OD officials have
also acknowledged that the centers operate as "silos," characterizing the
isolated manner in which these separate but related organizational
components operate.

OD has taken several steps to foster center collaboration on nonemergency
public health work. Conceptually, OD's emphasis on the five
themes-science, service, systems, strategy, and security-is part of an
approach to integrate the agency's public health work across the centers'
respective missions and functions. In August 2003, OD announced the
establishment of two governing bodies that encourage center
collaboration-the Executive Leadership Team and the Management

18U.S. General Accounting Office, Emerging Infectious Diseases: Consensus
on Needed Laboratory Capacity Could Strengthen Surveillance,
GAO/HEHS-99-26 (Washington, D.C.: Feb. 5, 1999).

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.19

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.

  Planning Tools That OD Needs to Manage Agency Priorities and Human Capital
  Challenges Are Not Yet Operational

19U.S. General Accounting Office, A Model of Strategic Human Capital
Management, GAO-02-373SP (Washington, D.C.: Mar. 15, 2002), and Human
Capital: Key Principles From Nine Private Sector Organizations,
GAO/GGD-00-28 (Washington, D.C.: Jan. 31, 2000).

    OD's Priority-Setting Efforts Have Lacked a Long-Term Focus

CDC has a strategic plan that has not been updated since 1994.
Consequently, this plan does not reflect the agency's more recent
challenges, such as preparing for terrorism-related events and
implementing the civilian portion of the national smallpox vaccination
campaign. In the absence of a current long-term strategy, OD has been
establishing priorities within its diverse mission through the annual
processes for developing the budget and updating goals for the agency's
annual performance report as required by the Government Performance and
Results Act of 1993 (GPRA). This method for setting priorities is not
effective for long-term planning, as its focus is on funding existing
activities one year at a time rather than examining agency goals and
performance from a broader perspective.

CDC's need for a comprehensive strategic plan is substantial, as OD must
set priorities based on disease prevention and control objectives inherent
in the agency's mission as well as any additional public health priorities
of HHS and the Congress. For example, in addition to addressing public
health program priorities, such as obesity and diabetes, CDC must also
address administration management priorities as directed by HHS.20
Moreover, the agency must keep a mission focus when coordinating with its
external partners-largely, state, local, and international public health
agencies. Although CDC relies heavily on these and other external partners
to achieve its mission, a mutual understanding of the agency's priorities
may be lacking. For example, some of the state and local public health
officials we spoke with were unable to articulate the agency's top
priorities aside from bioterrorism preparedness. CDC officials we spoke
with similarly acknowledged the need to better communicate priorities to
external partners.

Many of the centers have their own mission statements and a few also have
strategic plans to address individual center goals and priorities-a
reflection of the centers' independent focus. In the absence of an
agencywide plan, however, OD lacks an effective management tool to ensure
that the agency's priorities are being addressed without undue overlap or
duplication. In July 2003, participants in preliminary strategic planning
discussions acknowledged poor cooperation across centers and the need for
improvement in collaboration.

20The administration's management priorities are specified in the
President's Management Agenda, which addresses executive branch management
practices in the areas of human capital, competitive sourcing, financial
performance, electronic government, and the integration of budget and
performance.

    Strategic Planning Process Recently Initiated

In June 2003, OD initiated an agencywide strategic planning process called
the Futures Initiative, which is intended to involve all levels of staff
and some of the agency's partners in developing long-range goals and
associated performance measures. The agency's strategic planning efforts
will be focused on 10 topics: the public health system, customers' needs,
research capacity, communication and information priorities, future
resource needs, government partner relationships, measuring results,
intra-agency coordination, programs and grants portfolio, and global
health issues. In developing the strategy, OD intends to incorporate the
agency's mission and vision, the federal Healthy People 2010 goals, HHS's
strategic goals and objectives, and selected public health reports.21
However, at the time of our review, OD had not clearly linked the 10
topics and the agency's five mission themes of science, strategy, service,
systems, and security.

To guide and manage the agency's planning efforts, OD created a steering
committee, which is led by the agency's Director and consists of a small
group of senior officials from OD and the centers. This committee makes
recommendations to the Executive Leadership Team for decision making.
Under the committee, four initial work groups, consisting of center
representatives and some external partners, have been established to
examine the following topics: customers and partners, health systems,
health research, and global health.

CDC's overall strategic planning process has three phases. In the first
phase, CDC will evaluate the agency's overall direction and set
priorities. In the second, it will examine the agency's organizational
structure and processes and their alignment with the strategic plan's
goals and begin implementation. The last phase will focus on measuring
results and implementing the plan at all agency levels-both management and
staff. OD plans to begin implementing the strategy in spring 2004. OD
intends to communicate the results of the planning process internally to
staff and externally to agency partners through CDC's Web site and through
a variety of meetings and different venues.

According to the Senior Advisor for Strategy and Innovation, priority
issues and programs identified through the strategic planning process will

21Healthy People 2010 is a national health promotion and disease
prevention initiative that aims to improve the health of all Americans,
eliminate disparities in health, and improve years and quality of life.
These goals and objectives were launched by HHS and the Office of the
Surgeon General.

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.22

    Human Capital Plan Initiated but Recently Suspended

OD has been operating without a comprehensive human capital plan with
which to link workforce needs to agency priorities. The agency has several
separate initiatives under way in response to administration directives
regarding human capital management. However, in December 2002, HHS
criticized these efforts as being overly focused on the centers and
lacking an agencywide focus. In April 2003, OD began developing a
comprehensive, long-term human capital plan. In July 2003, OD suspended
the development of this plan until further progress could be made on the
agency's strategic planning process. As of November 2003, OD had not
established a date when the human capital planning would resume nor
determined how it would be coordinated with the agency's strategic
planning efforts.

Furthermore, CDC is facing several human capital challenges that
underscore the need for a strategy to address succession planning, which
involves preparing for the loss of key staff and their associated skills.
Leading organizations use succession planning and management as a tool
that focuses on current and future workforce needs in order to meet their
mission over the long term.23 Our analysis of CDC's 2003 personnel data
showed that-similar to the rest of the federal government-about 30 percent
of the agency's workforce is eligible to retire within the next 5 years.
We also found that 33 percent of its senior managers and

22U.S. General Accounting Office, Results-Oriented Cultures: Using
Balanced Expectations to Manage Senior Executive Performance, GAO-02-966
(Washington, D.C.: Sept. 27, 2002).

23U.S. General Accounting Office, Human Capital: Insights for U.S.
Agencies from Other Countries' Succession Planning and Management
Initiatives, GAO-03-914 (Washington, D.C.: Sept. 15, 2003).

supervisors will be eligible for retirement within this time frame.24
Thus, within several years, the agency could potentially lose a key
portion of its human capital that possesses both managerial and technical
expertise.25

In addition, by the end of fiscal year 2005, CDC and other HHS agencies
are expected to achieve a departmentwide 15 percent reduction in
administrative management and support positions. HHS mandated that this
reduction not result in the involuntary separations of employees and that
affected resources be redirected to programmatic public health work. The
implications for CDC are that within a 2-year time frame, CDC must
redirect 573 administrative positions from support activities to frontline
public health program activities. In some cases, this would involve
redirecting administrative staff to program work. However, this will pose
a challenge for CDC, as the agency does not maintain a repository of its
employees' skills, which is important to ensure appropriate employee
placement. HHS has also directed each of its agencies to assume no growth
in the number of FTEs beginning with the fiscal year 2005 budget
formulation process and to include a 5 percent FTE reduction option in
their budget submissions.

OD has taken modest steps toward succession planning. For example, CDC
participates in HHS's program to train and mentor emerging leaders. CDC's
Director has also emphasized the importance of identifying future leaders
within the agency and has made this issue a standing agenda item in
routine management meetings with center officials. To forecast workforce
needs, in August 2002, the agency produced a report of attrition for its
offices and centers. Currently, CDC's managers can access the most recent
attrition data by querying a Web-based personnel information system.
However, OD is limited in its ability to conduct targeted succession
planning or promote greater retention, as it does not track certain key
personnel information. For example, although resignations in calendar year
2002 accounted for a higher percentage of the agency's attrition than
retirement (30 percent compared with 20 percent),26 CDC

24Senior managers and supervisors were defined as positions at GS-14 or
higher-or the equivalent thereof. However, these data did not include
officials of the Public Health Service Commissioned Corps, who are
eligible to retire at 20 years of service and who must retire after 30
years of service.

25CDC's personnel data show that staff who are eligible to retire tend to
stay at the agency an average of about 3 years beyond their eligibility
dates.

26Other attrition was due to reasons such as death, termination of limited
appointments, and separation.

does not systematically document the reasons for resignations, either
through standard "exit interviews" of employees who leave the agency or
some other means.27 This lack of documentation limits OD's ability to
conduct comprehensive workforce planning, which includes strategies for
retaining an organization's workforce for meeting future needs.28

The considerable succession planning challenges that the agency faces
argue for greater OD leadership over human capital planning. Such
leadership would be consistent with the effective human capital planning
actions of six federal agencies cited in our April 2003 report on this
subject.29 The report noted, among other things, the importance of
including human capital leaders in key agency decision making and the
establishment and communication of a strategic vision by human capital
leaders. Currently, CDC does not have, as envisioned in these reported
best practices, a top-level leadership position focused on CDC's human
capital efforts.

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

Conclusions

27OD officials told us that some OD offices and centers give employees the
choice to participate in exit interviews. However, the offices and centers
use different methods in conducting these interviews.

28U.S. General Accounting Office, Human Capital: Key Principles for
Effective Strategic Workforce Planning, GAO-04-39 (Washington, D.C.: Dec.
11, 2003).

29U.S. General Accounting Office, Human Capital: Selected Agency Actions
to Integrate Human Capital Approaches to Attain Mission Results,
GAO-03-446 (Washington, D.C.: Apr. 11, 2003).

management in a reactive rather than leadership position. Despite efforts
made to encourage a better information flow between OD and the centers,
the reporting of important but nonemergency issues remains largely at the
discretion of the centers. Furthermore, efforts to foster collaboration
among centers for routine public health work have been made, but little
has been done to institutionalize such collaboration and avoid undue
overlap or duplication.

Third, OD is taking steps to manage the agency strategically, but key
planning tools are not fully in place. A recently announced strategic
planning process is intended to identify and communicate the agency's
optimal structure, processes, and performance measures. A human capital
plan was initiated in April 2003, but this effort has been postponed while
the strategic planning process gets under way. As of November 2003, no
time frames had been established for resuming the development of the human
capital plan or coordinating it with the strategic planning process. The
newness of the agency's strategic planning process and stalled workforce
planning efforts argue for greater leadership from OD to continue and
coordinate both efforts.

Recommendations for 	To improve OD's management of CDC's nonemergency
mission priorities, we recommend that the CDC Director take the following
three actions:

                                Executive Action

o  	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;

o  	ensure that reporting requirements and tracking systems are developed
for OD to routinely monitor the centers' operations and programmatic
activities; and

o  	develop incentives to foster center collaboration as a standard agency
practice.

We also recommend that the CDC Director take the following two actions:

o  	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

o  	ensure that the agency's human capital planning efforts receive
appropriate leadership attention, including resuming human capital
planning, linking these efforts to the agency's strategic plan, and
linking senior executives' performance contracts with the strategic plan.

  Agency Comments

In its written response to a draft of this report, CDC stated that it is
committed to continuing the positive changes we highlighted in the report
and agreed that challenges remain-especially for ensuring program
accountability. CDC acknowledged that continued oversight from OD is
critical to ensure high-quality management practices and scientific
excellence. The agency further emphasized that it is in the early stages
of a multiyear process of change.

CDC stated that ensuring program accountability is a significant challenge
that it takes most seriously as stewards of the public's trust and
funding. The agency agreed to evaluate our recommendation to realign and
clarify oversight for the centers' programmatic work at a level below the
Director in light of the management changes the agency has already
undertaken. CDC also stated that it is working to institute formal
reporting requirements and tracking systems that monitor center activities
with special emphasis on program outputs, outcomes, and impacts. In
addition, CDC stated that it continues to seek ways to strengthen center
collaboration. The agency also agreed with our recommendation regarding
its strategic planning process and provided information on how it has
involved both internal employees and external partners. CDC concurred that
human capital planning is critically important and stated that it will
link human capital planning and deployment to its strategic plan, and
appropriately connect the performance contracts of its senior executives
with the developing strategic plan. CDC also provided technical comments,
which we incorporated as appropriate. CDC's written comments are reprinted
in appendix II.

We are sending copies of this report to the Secretary of HHS. We will also
provide copies to others upon request. In addition, the report will be
available at no charge on GAO's Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at
(202) 512-7101 or Bonnie Anderson at (404) 679-1900. Hannah Fein,
Cywandra King, and Julianna Williams also made key contributions to this
report.

Sincerely yours,

Marjorie E. Kanof
Director, Health Care-Clinical Health Care Issues

                       Appendix I: Scope and Methodology

To assess the Centers for Disease Control and Prevention's (CDC) executive
management structure, we analyzed past and current organizational
structures and reporting arrangements. We interviewed the agency's
Director about the basis of the management reorganization and the roles of
the officials in the Office of the Director's (OD) management team. We
also interviewed the consultant who worked with agency management to help
develop the new OD structure. To identify changes resulting from the
reorganization, we spoke with past and current OD executive management
officials to discuss their roles and responsibilities, and we reviewed the
position descriptions for these officials. To ascertain the centers'
understanding of the roles of the OD management team, we interviewed
management officials from the following six centers: National Center for
Chronic Disease Prevention and Health Promotion; National Center for
Environmental Health; National Center for Health Statistics; National
Center for Infectious Diseases; National Center for HIV, STD, and TB
Prevention; and Public Health Practice Program Office. We also interviewed
management officials at the Agency for Toxic Substances and Disease
Registry, which functions similarly to CDC's centers. To assess the
demands on the Director's time, we identified high-profile public health
events and emergencies since the first West Nile outbreak in 1999. We also
analyzed the Director's calendar for the 7-month period covering January
1, 2003, through July 27, 2003.1

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

1CDC officials told us that some items of a sensitive nature were removed
from the calendar before it was given to us.

Appendix I: Scope and Methodology

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

Appendix I: Scope and Methodology

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.

Appendix II: Comments from the Centers for Disease Control and Prevention

Appendix II: Comments from the Centers for Disease Control and Prevention

Appendix II: Comments from the Centers for Disease Control and Prevention

Appendix II: Comments from the Centers for Disease Control and Prevention

Appendix II: Comments from the Centers for Disease Control and Prevention

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