Detailed Information on the
National Bioterrorism Hospital Preparedness Program Assessment

The program will review its current outcome-oriented performance measures and benchmarks, to ensure that they are evidence-based, and that they meet all of the legislative requirements of the Pandemic and All Hazards Act legislation, enacted December 2006.

The program will evaluate State and Regional based partnerships awarded in FY2007 that aim to improve overall surge capacity and capability and enhance hospital preparedness.

The Administration has reduced funding for these grants to pay for a new biosurveillance initiative that will assist states and hospitals respond to a bioterrorist event.

The Administration will work with State and local representatives to ensure that performance information will be available to determine when acceptable preparedness has been demonstrated, and to target assistance for those regions that are not adequately prepared.

The Administration will establish new outcome oriented goals and targets for surge capacity and preparedness. The program has established benchmarks for preparedness and is collecting data. PART measures, established early in the program's development, will be revised to align with these.

Measure: Percentage of hospital regions that have achieved a surge capacity of 500 persons per million in all hospital regions, for response to terrorism and other public health emergencies.

Explanation:The purpose of this measure is to better protect Americans by achieving a surge capacity of 500 persons per million in all hospital regions, for response to terrorism and other public health emergencies.

Measure: Percentage of awardees that have implemented regional plans and meet all major milestones established for all of the HRSA priority areas to meet the goal of a surge capacity of 500 persons per million population.

Explanation:The annaul performance measures established during the early stages of the Hospital Preparedness Program fail to reflect developments evident in the field of preparedness and do not reflect changes that have occurred in the program and nationally over the past 3 years. The program would like to propose new measures that align with the National Preparedness Goal and current program direction.

Measure: Percentage of awardees that will demonstrate their ability to secure and distribute pharmaceutical resources required in emergency events, including coordinated caches of pharmaceuticals from metropolitan medical response systems, sufficient to treat 500 persons per million population, as certified to by HRSA.

Explanation:The annual performance measures established during the early stages of the Hospital Preparedness Program fail to reflect developments evident in the field of preparedness and do not reflect changes that have occurred in the program and nationally over the past 3 years. The program would like to propose new measures that align with the National Preparedness Goal and current program direction.

Measure: Percentage of awardees that have (1) assessed the existing chemical and radiological response equipment they currently possess, (2) acquired the needed additional equipment as identified in that assessment, and (3) have trained hospital and emergency medical service personnel likely to respond/treat 500 persons per million population, chemically or radiological contaminated.

Explanation:The annual performance measures established during the early stages of the Hospital Peparedness Program fail to reflect developments evident in the field of preparedness and do not reflect changes that hve occurred in the program and nationally over the past 3 years. The program would like to propose new measures that align with the National Preparedness Goal and current program direction.

Measure: Percentage of awardees that have successfully demonstrated their ability to evaluate, diagnose, and treat 500 adult and pediatric patients per million population resulting from emergency events, meeting HRSA criteria, as evidenced in reviews of annual drill reports.

Explanation:The annual performance measures established during the early stages of the Hospital Preparedness Program fail to reflect developments evident in the field of preparedness and do not reflect changes that have occurred in the program and nationally over the past 3 years. The program would like to propose new measures that align with the National Preparedness Goal and current program direction.

Measure: Enhance State and local preparedness by increasing the ratio of preparedness exercises and drills per total program (Hospital Preparedness Cooperative Agreement) dollar by 50% each year.

Explanation:

Is the program purpose clear?

Explanation: The purpose of this program is to prepare hospitals and supporting healthcare systems to deliver coordinated and effective care to victims of terrorism and other public health emergencies.

Evidence: (1) Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Public Law 107-188) authorizes Sec. 319C of the Public Health Service Act. (2) Funding provided in 2003 Consolidated Appropriations Act (Public Law 108-7)

Does the program address a specific and existing problem, interest, or need?

Explanation: The need to improve hospital and healthcare system preparedness in the case of an attack or other public health emergency remains. The risk of attack was made clear by the events of September 11, 2001 and the antrax attacks of the fall of 2001. GAO reports have documented wide-spread deficiencies in the capacity, communication, coordination and training elements required for preparedness and response. In May, 2001, an Americal Journal of Public Health Survey was published results indicating a lack of preparedness, including: less than half (45%) of hospitals had an indoor or outdoor decontamination unit with isolated ventilation, shower, and water containment systems, but only 12% had 1 or more self-contained breathing apparatuses or supplied air-line respirators. Only 6% had the minimum recommended physical resources for a hypothetical sarin incident.

Evidence: (1) GAO Report 03-373, "Bioterrorism: Preparedness Varied across State and Local Jurisdictions" (2) GAO Report 02-149T, "Bioterrorism: Review of Public Health Preparedness Programs" (3) GAO Report 02-141T, "Public Health and Medical Preparedness" (4) American Journal of Public Health Preparedness, May, 2001 - www.ajph.org/cgi/content/abstract/91/5/710

Is the program designed so that it is not redundant or duplicative of any Federal, state, local or private effort?

Explanation: This is the only program whose mission is focused on preparing hospitals and other health care providers to respond to a terrorist attack or mass casualty emergency. CDC's grant program focuses on public health infrastructure, and DHS first responder grants focus on emegency (non-medical) response.

Evidence: (1) Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Public Law 107-188) authorizes this activity as part of an overall, coordinated approach to public health preparedness, including CDC public health grants.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: There is no evidence that a different design would be more effective. HRSA approves each state's planned use of these funds, ensuring that they are used for their intended purpose. In addition, the cooperative agreement guidance prohibits supplantation, and HRSA project officers are required to address this point with awardees.

Evidence: National BHPP Cooperative Agreement Guidance for FY 2003

Is the program effectively targeted, so program resources reach intended beneficiaries and/or otherwise address the program's purpose directly?

Explanation: Funds are distributed through a Congressionally established formula that provides every state with a base amount, and the remainder through a population factor. This design ensures that every state can make some capacity improvements, while larger states receive greater assistance. However, this design is not optimal past the short term. Currently, most states have great need and can put the base amount to good use. However, this will not always be the case. In addition, population is not an exact proxy for need of assistance. To avoid distributing scarce resources to states with lesser need, assessments should be done to determine each state's capacity compared to its need. Funding should be distributed to states according to their need for assistance, and demonstrated ability to use funds to make the required improvements. Otherwise, the program can not be accurately described as effectively targeted. HRSA has taken the appropriate approach of making funds available for capacity enhancements on a regional basis, rather than providing equal capacity to every hospital. This increases cost effectiveness, and diminishes the extent to which funding is provided to entities that do not need it.

Evidence: National BHPP Cooperative Agreement Guidance for FY 2003

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation:  

Evidence: see Measures tab

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation:  

Evidence: see Measures tab

Does the program have a limited number of specific annual performance measures that demonstrate progress toward achieving the program's long-term measures?

Explanation:  

Evidence: see Measures tab

Does the program have baselines and ambitious targets and timeframes for its annual measures?

Explanation:  

Evidence: see Measures tab

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, etc.) commit to and work toward the annual and/or long-term goals of the program?

Explanation: Awardees are committed to the annual and long-term goals of the program, as established in the cooperative agreement guidance.

Evidence: National BHPP Cooperative Agreement Guidance for FY 2003

Are independent and quality evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: No independent evaluations have been conducted.

Evidence:  

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: Budget submissions are not tied to the achievement of specific performance targets. States must report what they do with grant funds, and HRSA can ensure that funds are used consistent with broad program goals and focus areas, but funding requests are not tied to achievement of specifc goals within specific timeframes. Budget requests are not detailed enough, and funding levels are tied more to total authorization level than to specific objectives.

Evidence:  

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: HRSA has not made arrangements to establish an independent evaluation, and there is no evidence that budget requests will be handled differently.

Evidence:  

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: Performance data is reported semi-annually by each State. HRSA then tabulates this data into a comparative data report, which is used during weekly awardees calls to make awardees aware of trends and other useful information.

Evidence: Cooperative Agreement allows HRSA to tailor information requirements.

Are Federal managers and program partners (grantees, subgrantees, contractors, cost-sharing partners, etc.) held accountable for cost, schedule and performance results?

Explanation: Federal and state managers are not yet held accountable for program performance in a systematic way.

Evidence: Federal managers track state performance, including the establishment of certain key positions, (see BHPP Database Report) but do not use program performance to hold managers accountable.

Are all funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: Federal funds from this program have been obligated in an extremely timely manner. Information on state obligations not made available. HRSA ensures that funds are used for their intended purposes.

Evidence: The Secretary made it a priority for both CDC and HRSA to release these funds as soon as possible. Federal funds were appropriated on January 10, 2002 and 20% were released by CDC to state by February, with the remainder released in June, 2002. All funding requests are reviewed for consistency with program purpose.

Does the program have procedures (e.g., competitive sourcing/cost comparisons, IT improvements, approporaite incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: While HRSA does take some steps to promote efficiencies, without efficiency goals included in their strategic planning and performance plans, other steps are insufficient.

Evidence: Performance measures do not include any efficiency goals. While HRSA does take steps to cost-effectiveness, including adopting a model of regional preparedness rather than equal improvements to every hosptial or health care center -- such steps are insufficient without a focus on cost-effectiveness and efficiency in strategic and performance planning.

Does the program collaborate and coordinate effectively with related programs?

Explanation: This program, along with the CDC Public Health Preparedness Grants program has been an example of coordination within HHS. HRSA has also required coordination with entities outside of HHS in the cooperative agreement guidance, and to report on such coordinated activities in the semi-annual reports.

Evidence: HHS has taken steps to ensure coordination within the Department, with the Assistant Secretary for Public Health and Emergency Preparedness taking a strong role in coordinating HRSA and CDC efforts in this area. This includes joint grant announcements, and simultaneous release of funding, and cross-references in HRSA and CDC cooperative agreements. In addition, HHS has entered into a Memorandum of Agreement with DHS on related/shared responsibilities. See also BHPP Cooperative Agreement Guidance for FY 2003.

Does the program use strong financial management practices?

Explanation: The September 30, 2002 and 2001 independent auditor's report identifies five reportable conditions. 1) Preparation and analysis of financial statements - HRSA's process for preparing financial statements is manually intensive and consumes resources that could be spent on analysis and research of unusual accounting. 2) HEAL program allowance for uncollectible accounts ' HRSA's financial statements indicate limited success in collecting delinquent HEAL loans. 3) Federal Tort Claims Liability ' HRSA is unable to estimate its malpractice liability under the Health Centers program. 4) Accounting for interagency grant funding agreements ' HRSA's interagency grant funding agreement transactions are recorded manually and are inconsistent with other agencies' procedures. 5) Electronic data processing controls ' HRSA has not developed a disaster recovery and security plan for its data centers. Although HRSA's hospital preparedness program has not been cited specifically by auditors for material weaknesses, the above reportable conditions constitute weaknesses within HRSA and its Office of Financial Integrity. The Office reports directly to the Administrator and is intended to ensure procedures are in place to provide oversight of all of HRSA's financial resources.

Evidence: 1) CORE Accounting Form 2) HRSA Office of Financial Integrity description 3) HRSA FY 2002 Annual Report

Has the program taken meaningful steps to address its management deficiencies?

Explanation: HRSA has used information gathered so far to to adjust the guidance, and include an improved electronic budget table developed based on state feedback that now assists States in managing their resource allocations. In addition, HRSA will be implementing a number of IT improvements to increase efficiency and improve program management. Finally, HRSA developed a corrective action plan to address the reportable conditions identified in the September 30, 2002 and 2001 independent auditor's report. For each aspect of the five reportable conditions, HRSA assigned an office responsibility. The plan also outlines milestones and target completion dates.

Evidence: Evidence includes: 1) National BHPP Cooperative Agreement Guidance for FY 2003; 2) HRSA Corrective Action Plan for FY2002 Financial Statement Audits as of 4/30/2003.

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: Cooperative agreement guidance requires semi-annual reporting on awardee activities. HRSA project officers also conduct site-visits and regular conference calls with awardees.

Evidence: National BHPP Cooperative Agreement Guidance for FY 2003

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The program collects information from awardees semi-annually, and summarizes it in a database. However, information is not made available publicly, in part due to security concerns.

Evidence:  

Has the program demonstrated adequate progress in achieving its long-term outcome performance goals?

Explanation: The program has really only had one year of funding, in FY 2002 - and at a much lower level than was provided for FY 2003 and requested for FY 2005. Therefore, there is not yet strong information to demonstrate progress toward long-term goals.

Evidence:  

Does the program (including program partners) achieve its annual performance goals?

Explanation: Reports from the first year of funding show a degree of initial progress, particularly in the area of planning.

Evidence: Information reported from May, 2002 application and November 2002 semi-annual report.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program performance goals each year?

Explanation: Program only begun in FY 2002 - with only one year of funding, there is no way to demonstrate improved efficiency.

Evidence:  

Does the performance of this program compare favorably to other programs, including government, private, etc., that have similar purpose and goals?

Explanation: This program has existed for a shorter period of time, and therefore cannot demonstrate similar progress to other efforts designed to increase preparedness against a terrorist attack or public health emergency. However, initial progress made with funding in its first year indicates, to some extent, a favorable comparison.

Evidence:  

Do independent and quality evaluations of this program indicate that the program is effective and achieving results?

Explanation: No independent evaluations have been conducted as this program was first funded in FY 2002.

Evidence: No independent evaluations have been conducted.