Public Health and Hospital Emergency Preparedness Programs:

Evolution of Performance Measurement Systems to Measure Progress

GAO-07-485R: Published: Mar 23, 2007. Publicly Released: Apr 25, 2007.

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Cynthia A. Bascetta
(202) 512-7207


Office of Public Affairs
(202) 512-4800

The September 11, 2001, terrorist attacks, the anthrax incidents during the fall of 2001, Hurricane Katrina, and concerns about the possibility of an influenza pandemic have raised public awareness and concerns about the nation's public health and medical systems' ability to respond to bioterrorist events and other public health emergencies. From 2002 to 2006, the Congress appropriated about $6.1 billion to the Department of Health and Human Services (HHS) to support activities to strengthen state and local governments' emergency preparedness capabilities under the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Preparedness and Response Act). HHS has distributed funds annually to 62 recipients, including all 50 states and 4 large municipalities, through cooperative agreements under two programs--the Centers for Disease Control and Prevention's (CDC) Public Health Emergency Preparedness Program, and the Health Resources and Services Administration's (HRSA) National Bioterrorism Hospital Preparedness Program. The common goal of CDC's and HRSA's preparedness programs is to improve state and local preparedness to respond to bioterrorism and other large-scale public health emergencies, such as natural disasters or outbreaks of infectious disease. Annually, both CDC and HRSA develop and issue program guidance for recipients that describes activities necessary to improve their ability to respond to bioterrorism and other public health emergencies and sets out requirements for measuring their performance. Each recipient is required to submit periodic reports that track progress in improving their preparedness. As a result of the nation's ineffective response to Hurricane Katrina and the need to prepare for a possible influenza pandemic, members of the Congress have raised questions about CDC's and HRSA's efforts to monitor the progress of their preparedness programs. Because of these questions, we are reporting on (1) how CDC's and HRSA's performance measurement systems have evolved and (2) how CDC and HRSA are using these systems to measure the progress of their preparedness programs.

Since 2002, CDC's and HRSA's performance measurements have evolved from measuring capacity to assessing capability. Early in their programs, both agencies used markers or values that they called benchmarks to measure capacity-building efforts, such as purchasing equipment and supplies and acquiring personnel. These benchmarks were developed from activities authorized in the Preparedness and Response Act. In 2002, CDC established 14 benchmarks, such as requiring each recipient to designate an executive director of the bioterrorism and response program, establish a bioterrorism advisory committee, and develop a statewide response plan. From 2003 to 2005, CDC further developed its performance measurements by obtaining input from stakeholders to make a transition from using benchmarks focused on capacities to using performance measures focused on capabilities, such as whether personnel have been trained and can appropriately use equipment. In 2006, CDC continued to work with stakeholders to refine its performance measures. At the beginning of its program in 2002, HRSA established 5 benchmarks, such as requiring each recipient to designate a coordinator for bioterrorism planning, establish a hospital preparedness committee, and develop a plan for hospitals to respond to a potential epidemic. From 2003 to 2005, HRSA modified existing benchmarks and added new ones, such as training benchmarks, based on the existing legislation and input from stakeholders. In 2006, HRSA convened an expert panel to propose a set of performance measures focused on capabilities. CDC and HRSA officials told us they will continue to face challenges as their performance measures evolve, such as gaining consensus among stakeholders in light of minimal scientific data about public health and hospital emergency preparedness. CDC and HRSA use data from recipients' reports and site visits to monitor recipients' progress in improving their ability to respond to bioterrorism events and other public health emergencies. CDC and HRSA project officers use performance measurement data from recipients' required progress reports, along with site visits, to monitor progress and provide feedback about whether individual recipients have accomplished activities related to their ability to respond to bioterrorism events and other public health emergencies. Currently, there are no standard analyses or reports that enable CDC and HRSA to compare data across recipients to measure collective progress, compare progress across recipients' programs, or provide consistent feedback to recipients. However, in mid to late 2006 both agencies began developing formal data analysis programs that are intended to validate recipient-reported data and assist in generating standardized reports. According to CDC officials, CDC plans to finish validation projects by August 2007 and then develop routine reports summarizing individual recipient and national progress. In addition, CDC plans to issue a report by the end of 2007 providing a "snapshot" of the progress recipients have made in building emergency readiness capacity and addressing how CDC will measure capability in the future. However, because of the expected move of HRSA's program to a different HHS office in 2007, its schedule for finishing data validation was tentative at the time we briefed your staff. Furthermore, due to the expected move, HRSA officials said at that time that decisions about whether to issue a report in 2007 on recipients' progress also had not been made.

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