Detailed Information on the
CDC: State and Local Preparedness Grants Assessment

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 areas that are not adequately prepared.

Develop and conduct independent program evaluations.

In collaboration with grantees, CDC will revise existing program standards and measures and to develop new standards and measures due to PAHPA requirements

Reduced funding for these grants to pay for a new biosurveillance initiative that will also be of great value to states and local health departments.

Has established outcome oriented goals and targets for preparedness.

Measure: GOAL 1: To rapidly detect public health emergencies involving biological, chemical, radiological and nuclear agents.

Explanation:This is one of three major program goals. However, each goal is essentially untestable in the absence of a terrorist attack or other major public health emergency. Therefore, long-term measures and annual targets have been chosen for each as proxies for the actual long-term goal.

Measure: Percentage of LRNs the pass proficiency testing for agents on the CDC's Category A threat list

Explanation:Proficiency standards are established in LRN guidelines. Agents include: bacillus anthracis, yersina pestis, Francisilla tularensis, Clostridium, botlulinum toxin, variola major, vaccinia and varicella.

Measure: Percentage of Laboratory Response Network labs that pass proficiency testing for Category A threat agents

Explanation:

Measure: Percentage of states with level 1 chemical lab capacity, and agreements with/access to a level 3 chemical lab (specimens arriving within 8 hours)

Explanation:This measure requires 1 level-1 chemical lab in every state, and access to a level-3 equipped to detect exposure to nerve agents, mycotoxins and select industrial toxins.

Measure: Percentage of states with level 1 chemical lab capacity, and agreements with/access to a level 3 chemical lab (specimens arriving within 8 hours)

Explanation:

Measure: GOAL 2: To rapidly investigate and respond to public health emergencies involving biological, chemical, radiological and nuclear agents.

Explanation:This is one of three major program goals. However, each goal is essentially untestable in the absence of a terrorist attack or other major public health emergency. Therefore, long-term meausures and annual targets have been chosen for each as proxies for the actual long-term goal.

Measure: Percentage of LRN laboratories that report routine public health testing results through standards-based electronic disease surveillance systems, and have protocols for immediate reporting of Category A agents.

Explanation:

Measure: GOAL 3: To rapidly control, contain and recover from public health emergencies involving biological, chemical, radiological and nuclear agents.

Explanation:This is one of three major program goals. However, each goal is essentially untestable in the absence of a terrorist attack or other major public health emergency. Therefore, long-term meausures and annual targets have been chosen for each as proxies for the actual long-term goal.

Measure: Percentage of public health agencies that directly receive CDC PHEP funding that can convene within 60 minutes of notification a team of trained staff that can make decisions about appropriate response and interaction with partners.

Explanation:

Measure: Percentage of state public health agencies that are prepared to use materiel contained in the SNS as demonstrated by evaluation of standard functions as determined by CDC

Explanation:Public health agencies must be able to rapidly convene staff to integrate information and prioritize resource allocation to ensure timely and effective coordination within the public health agency and with key response partners during an emergency response.

Measure: Percentage of state public health laboratories that directly receive CDC PHEP funding that can correctly subtype E. Coli O157:H7 and submit the results into a national reporting system within 4 working days for 90% of the samples received. (New measure, added February 2008)

Explanation:Public health agencies must be able to inform local, state, and national laboratorians and epidemiologists of disease occurrences in a timely manner in order to determine the extent and scope of potential outbreaks and to minimize the effects of these outbreaks.

Measure: Percentage of public health agencies that directly receive CDC PHEP funding that, at least once/year, re-test a response following completion of corrective action(s) identified in a prior actual or simulated response. (New measure, added February 2008)

Explanation:Public health agencies must be able to systematically re-test their response capabilities in order to provide evidence that planned and implemented corrective actions have been effective in improving response capacity.

Measure: Create program efficiencies that improve services and conserve resources for mission-critical activities.

Explanation:Decrease the amount of time it takes the Division of State and Local Readiness (DSLR) Project Development Officers to conduct technical reviews of work plans and budgets for all 62 grantees by providing appropriate tools and functionality in the DSLR Management Information System (MIS).

Is the program purpose clear?

Explanation: The purpose of these grants are to improve state and local public health capacity to respond to terrorist attacks and emergencies, in the event of a biological, chemical or radiological/nuclear attack.

Evidence: (1) Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Public Law 107-188) (2) Funding provided in 2001 Emergency Supplemental Appropriation (Public Law 107-38), 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 state and local preparedness remains. The risk of attack was made clear on September 11, 2001 and the subsequent anthrax attack in the fall of 2001. Recent reports indicate that gaps exist in the public health infrastructure's ability to respond to such attacks and emergencies.

Evidence: (1) GAO Report 03-373, "Bioterrorism: Preparedness Varied across State and Local Jurisdictions" (2) GAO-03-769T, testimony before the Subcommittee on Oversight and Investigations (3) GAO Report 02-149T, "Bioterrorism: Review of Public Health Preparedness Programs" (4) GAO Report 02-141T, "Public Health and Medical Preparedness" (5) Association of Public Health Laboratories June 2003 report, "Public Health Laboratories, Unprepared and Overwhelmed" - http://healthyamericans.org/resources/files/LabReport.pdf (5) IOM - "Biological Threats and Terrorism: Assessing the Science and Response Capabilities" http://books.nap.edu/books/0309082536/html#pagetop

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

Explanation: There is some natural overlap since there are a number of programs that exist to improve national preparedness against terrorist attacks. However, this is the only program with the explicit purpose of improving state and local public health capacity. In addition, CDC has worked to coordinate with other agencies performing related missions, both within and outside of HHS. These include the Department of Homeland Security, and the Health Resources and Services Administration.

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.

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. CDC approves each state's planned use of these funds, ensuring that they are used to improve public health preparedness/response capacity. CDC will not approve state budgets that supplant other funding sources. CDC conducts monitoring/oversight visits to state programs, which include fiscal review.

Evidence: Cooperative Agreement guidance

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 preparedness 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, but this will not always be the case. In addition, population is not an exact proxy for need of assistance. To avoid an automatic provision of scarce resources to states with lesser need, assessments should be done to determine each state's preparedness 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.

Evidence: (1) Cooperative Agreement guidance (2) Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Public Law 107-188)

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: States and other partners are committed to the annual and long-term goals of the program, as established in cooperative agreements.

Evidence: (1) CDC State Local Preparedness Cooperative agreement guidance (2) cooperative agreements have also been entered into with additional partners, including (ASTHO, NACCHO, CSTE and APHL) to work toward annual/long term goals of the program.

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: There have been no comprehensive independent evaluations of the program that would lead to program improvements. CDC requested that the HHS IG, Office of Evaluations and Inspections review the program.

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: Congressional Justification materials do not identify spending categories in sufficient detail. Further, since states determine allocation of total funding, CDC can not tie funding levels to achievement of specific goals.

Evidence: FY 2001 - FY 2004 CDC Congressional Justifications. Cite cooperative agreement

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

Explanation: There are no plans as of yet for independent evaluations.

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: CDC requires funding recipients to submit semi-annual progress reports, project officers conduct site visits, and while there is not enough experience yet with this program to demonstrate full use of performance data to improve future program performance, these reporting mechanisms and CDC staff activities are designed to acheive that end.

Evidence: (1) Financial Status Reports are ue 90 days after end of fiscal year. (2) CDC Project Officers conduct site visits, with resulting reports that include recommendations to states. (3) States were initially awarded funds by specific focus area, but as a result of semi-annual report, current guidance provides a process for managing redirection between focus areas, or carryover from one fiscal year to the next.

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

Explanation: There are no current mechanisms in use to incorporate program performance into federal managers performance evaluation criteria.

Evidence: Performance contracts are not used.

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. State obligations have been less timely, in large part due to the major increase in funding level, and subsequent ramp-up in state expenditures. CDC ensures that funds are used for their intended purposes.

Evidence: (1) 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. (2) State spending reports will be available 90 days after end of FY2002, but current estimates indicate that 94% will be obligated by end of FY2002. (3) All funding requests are reviewed for consistency with program purpose. Any inconsistent requests are disallowed. All post-award budget changes must be approved by CDC.

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 CDC 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 CDC does take steps to promote efficiency, including project officer review of funding requests for cost effectiveness, ensuring that states follow their own procuremnt regulations with these funds, and allowing states to purchase items with grant funds through large scale federal procurements as appropriate -- these steps are secondary and 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 HRSA Hospital Preparedness has been an example of coordination within HHS. CDC has also taken actions to coordinate with DHS programs with similar focus, including the Office of Domestic Preparedness.

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.

Does the program use strong financial management practices?

Explanation: The FY 2002 report noted reportable conditions relating to information systems; the internal controls over preparation, analysis and monitoring of financial information, including manually intensive procedures; reimbursable agreements; and grants accounting and oversight. None of the reportable conditions are considered material internal control weaknesses. CDC has actively addressed key areas. CDC automated reimbursable billings, enhanced year end closing transactions and implemented a new indirect cost methodology. CDC is also addressing staffing needs, including core accounting competencies, professional staff recruitment, financial systems, training and customer service.

Evidence: Evidence includes the FY 2002 Chief Financial Officers annual report, including summary of reportable conditions, summary documents on end of year balances, OIG reports (e.g., CIN-A-04-98-04220). Four areas of findings were also documented the prior year. CDC has received five consecutive unqualified opinions on the agency's financial statements. Additional data include that CDC issued 64 duplicate or erroneous payments in FY 2002, or 0.042% of all payments and has a 97% compliance rate for prompt payments.

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

Explanation: CDC has made and is continuing to make improvements to financial management processes, including restructuring its budget and financial accounting system to more accurately track CDC's expenditures and hiring a consulting firm to develop a more consistent and accurate system for charging overhead. CDC initiated changes in core accounting competencies, professional staff recruitment, financial systems training, and customer service. CDC will transition to HHS' Unified Financial Management System and will automate the financial accounting processes. Also, responsibility for the cooperative agreement was moved to the Office of the Director of CDC in October 2002. This move was designed to improve coordination of program activities within CDC and to centralize management of the activities related to this cooperative agreement.

Evidence: CDC will be the first to pilot HHS' Unified Financial Management System in October 2004. CDC launched a technical team and business transformation team to implement new procedures and improve their process. Creation of Office of Terrorism Preparedness and Response within the Office of the Director. Also see (3) in evidence for question 3.1

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

Explanation: Cooperative agreement guidance requires semi-annual reporting on activities in each focus area. CDC project officers also conduct site-visits and regular conference calls with grantees.

Evidence: Cooperative Agreement guidance

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: Information is collected on a semi-annual basis, but not necessarily made available to the public due to sensitivity/security concerns. Greater effort could be made to summarize non-sensitive information and release progress reports to the public for this magnitude of investment.

Evidence: Information deemed sensitive by CDC legislative counsel.

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

Explanation: Some results have been demonstrated. However, since the program is relatively new, and the performance goals have just been agreed to this year, progress demonstrated does not exceed small extent.

Evidence: Examples from the FY 2002 Progress Report include: (1) Prior to 2002, no states had a smallpox response plan - 42% of states have now developed both pre-event and post-even smallpox response plans. (2) 45 states have developed reportable disease surveillance systems. (3) Many (?) states have reported that their laboratories can now test for 4 of the 5 Category A agents. (4) 67% of grantees have developed an epidemiologic response plan that addresses surge capacity, delivery of mass prophylaxis and immunizations. (5) 91% of grantees can initiate a field investigation 24/day, 7 days/week in all parts of their state within 6 hrs of receiving an urgent disease report.

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

Explanation: Some results have been demonstrated. However, since the program is relatively new, and the performance goals have just been agreed to this year, progress demonstrated does not exceed small extent.

Evidence: see above. Long-term and annual goals are aligned.

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

Explanation: Performance measures do not include any efficiency goals. However, a number of other choices made regarding program management/structure include attempts at efficiency and cost-effectiveness.

Evidence: See Measures tab. Other steps promoting efficiency and cost effectiveness include promotion of distance learning through Health Alert Network, Regional approach to Laboratory Response Network rather than equipping every laboratory in a sometimes redundant fashion, and the institution of an electronic application.

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

Explanation: There is not a large body of evidence of progress compared with similar programs such as first responder grants from DHS, or hospital preparedness grants from HRSA. However, given that this cooperative agreement is relatively new, the progress that has been demonstrated indicates initial performance levels that are, to some extent, favorable as compared with other programs.

Evidence: No evidence provided of comparison between the DHS Office of Domestic Preparedness first responder grants and this program. HRSA program is very new, and there is insufficient performance information to make a fair comparison. However, the initial progress demonstrated (see above) are all accomplishments that would not have been achieved without this program. Therefore, at least to some extent, it is performing favorably compared to programs with similar purpose and goals.

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

Explanation: Independent evaluations have not yet taken place.

Evidence: