Detailed Information on the
Poison Control Centers Assessment

Assist grantees with implementing and reporting on initiatives to address financial stability.

Proposes a reduction in funding of $13 million below the FY 2005 House appropriation level in an attempt to increase the cost effectiveness of the program through investment in fewer and more regionalized PCCs that could perform the same role as a large number of local PCCs. Because a significant portion of this program??s funds have gone to stabilizing PCCs, of which 48 out of 62 are now considered stable and certified, the program should not require the same level of funding it has received in previous years.

Will work to establish a performance-based budget that demonstrates the impact of the Administration's funding decisions.

Collect and report on performance using newly developed measures.

Collect and report on performance using newly developed measures.

Measure: Reduce percent of emergency room visits due to poisoning

Explanation:The program will help to reduce the number of individuals unnecessarily visiting the emergency room as a result of poisoning or suspected poisoning by 25 percent.

Measure: Increase percent of inbound volume on the toll-free number

Explanation:By increasing the use of 1-800-222-1222, individuals will be able to take the necessary steps to determine the severity of the situation and respond accordingly, which will help to reduce the number of emergency room visits. Some targets may be shown as NA (not applicable) because the program is not proposed for funding.

Measure: Increase the number of PCCs with 24-hour bilingual staff

Explanation:By increasing the number of PCCs with bilingual staff by at least 2 centers per year the program will be able to serve a large population, which will help to reduce the number of emergency room visits. Some targets may be shown as NA (not applicable) because the program is not proposed for funding.

Measure: Develop and ratify evidence-based guidelines for the treatment of poisoning

Explanation:By increasing the number of guidelines ratified, PCCs will respond to callers with more consistent actions, which will help to reduce the number of emergency room visits.

Measure: Decrease the application and reporting time burden of grantees by 5% per year for 4 years, thereby collecting moe accurate and timely data.

Explanation:Some targets may be shown as NA (not applicable) because the program is not proposed for funding.

Is the program purpose clear?

Explanation: Although the statute does not contain a purpose section, Congressional findings and directives clearly express its intent for the Poison Control Centers (PCCs) program ' to help stabilize and improve PCCs and promote a comprehensive system for the delivery of high quality poison control services nation-wide. As amended, the statute reauthorizes the PCCs program through 2009 and directs the Secretary to: 1) award grants to regional, certified PCCs to help them achieve financial stability that they may provide treatment recommendations for poisonings, 2) provide coordination and assistance to regional PCCs to establish and maintain a national toll-free number to be used across centers and 3) establish a national media campaign to educate the public and providers about poison prevention.

Evidence: Evidence 1. Poison Control Center Enhancement and Awareness Act - Section 1271-1274 of the Public Health Service Act, as amended (42 USC 300d) - P.L.108-194 Background The first poison control center was established in 1953; by 1954 11 centers had been established in the city of Chicago alone, with the objective of providing information to physicians for treatment of children exposed to toxic agents. There are currently 62 PCCs in 41 States and Territories. The PCCs program was established in February 2000 to provide a source of supplemental support to poison control centers. This program is administered by the Health Resources and Services Administration (HRSA). When Congress passed the Poison Control Center Enhancement and Awareness Act it indicated its expectation that increased stability of these centers would decrease the inappropriate use of emergency medical services and other costly health care services. The program was reauthorized in 2003.

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

Explanation: The program has made considerable progress in addressing its purpose; 6 of the 7 PCCs on the verge of closing at the inception of the program in 2000 have been stabilized through Stabilization Grants, 48 of the 62 PCCs have received Enhancement Grants to ensure the necessary infrastructure and staff are in place to maintain the centers, the national toll-free number has been established, and numerous media campaigns have been conducted. It is the case that incidences of poisoning occur each year; however, PCCs are now better equipped to handle such suspected occurrences. Poisoning is the third most common form of unintentional death in the United States. Each year there are between 2-4 million actual or suspected poison exposures. According to the American Association of Poison Control Centers (AAPCC), in 2002, more than 2.1 human exposure calls were received by all PCCs combined, which lead to a determination, by a health professional, if a poisoning occurred. More than 50 percent of exposures involve children under age six. Poisonings account for nearly 300,000 hospitalizations and 13,000 fatalities each year. During the aftermath of the events of September 11, 2001 and the anthrax incidents of October 2001, these centers experienced increased call volume and answered thousands of calls from concerned individuals.

Evidence: Evidence 1. Section 2 of the Poison Control Center Enhancement and Awareness Act Amendments of 2003, (P.L.108-194) 2. American Association of Poison Control Centers - Rebecca Rembert, A Profile of U.S. Poison Centers In 2002

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

Explanation: HRSA's PCCs program complements the efforts of other Federal agencies. Other agencies focus on the prevention of poisonings, while HRSA ensures that if a poisoning occurs or is suspected, individuals have access to medical advice to determine possible next steps. By providing immediate information in the event of a poisoning, the PCC program can help to reduce emergency room visits by providing guidance to individuals in their homes. HRSA and HHS' Centers for Disease Control and Prevention (CDC) were tasked with jointly leading the Department's efforts in this area. Eighty-one percent of HRSA's PCC funding is used to help sustain the infrastructure and operation of PCCs. CDC funds the maintenance of the toll-free number, that national media campaign, and the American Association of Poison Control Center's (AAPCC) efforts to: upgrade its Toxic Exposure Surveillance System (TESS), a proprietary data and surveillance system that is recently able to provide real-time data to: identify early markers for chemical and bioterrorism events; identify emerging problems with newly-introduced household products, pesticides, and pharmaceuticals; identify emerging drug and substance abuse issues; and determine the clinical profile of poisonings with new chemicals, pharmaceuticals and products. (See "Evidence" for a summary of other agencies' activities.)The Stabilization and Grant Program is divided into three parts: 1) Financial Stabilization Grants for certified PCCs to improve services, such as improvetelecommunications or computer capabilities, increase public education and outreach and increase staff, 2) Certification Grants to assist non-certified centers in achieving certified status, and3) Incentive Grants to encourage centers collaboration. Also, the program funds through a cooperative agreement with the AAPCC, Patient Management Guidelines which are a series of courses of action to treat a particular poisoning.

Evidence: Evidence1. www.atsdr.cdc.gov/training/public-health-assessment-overview/html/module1/sv3.html2. www.cpsc.govBackgroundThe Food and Drug Administration's (FDA) provided support services but no direct funding to PCCs. Participation in NCHPCC's statistical reports was voluntary. The FDA ceased its work in this area in 1987.The Agency for Toxic Substances and Disease Registry has as its primary mission preventing or reducing adverse human health effects (illnesses) and the diminished quality of life associated with exposure to toxic waste sites, spills or uncontrolled releases, and sites for which individuals or groups have requested ATSDR's assistance. Consumer Product Safety Commission (CPSC) is charged with protecting the public from unreasonable risks of serious injury or death from more than 15,000 types of consumer products under the agency's jurisdiction. For example, CPSC helps prevent poisonings by requiring child-resistant packaging for medicines and hazardous household chemicals.

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

Explanation: The current program design is not free of major flaws that may limit the program's effectiveness and efficiency. The program funds 62 PCCs across the nation. Fewer PCCs may be more cost effective and efficient than 62 separate PCCs--each developing its own version of guidelines for protocols. The Institute of Medicine (IOM) considered the strengths and weaknesses of options for the number and distribution of PCCs. The IOM concluded that decisions about the number of centers should be based on considerations of population coverage, telecommunication capabilities, and types of funding. The IOM also believes a single national PCC would be vulnerable to power failures, limited surge capacity and potential transmission lags during times of high volume, and that there may be economies of scale and scope that can be achieved through a regionalized approach.

Evidence: Evidence 1. Sections 1271-1274 of the Public Health Service Act, as amended (42 USC 300d) - P.L.108-194 -- The Poison Control Center Enhancement and Awareness Act 2. Poison Control Centers Stabilization and Enhancement Grant Program, Financial Stabilization Grants: Program Guidance (FY 2004) 3. Institute of Medicine - Forging a Poison Prevention and Control System (April 2004)

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

Explanation: Though there is room to improve efficiency, the program is effectively targeted so that resources reach intended beneficiaries and address the program's purpose. Eligibility for funding is limited to Poison Control Centers only and is provided directly to the centers.

Evidence: Evidence Poison Control Centers Stabilization and Enhancement Grant Program, Financial Stabilization Grants: Program Guidance (FY 2004)

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: The program developed a new long-term output goal that is directly linked to improved health outcomes for those possibly exposed to a toxic agent. When Congress passed the Poison Control Center Enhancement and Awareness Act it indicated its expectation that increased stability of PCCs would decrease the inappropriate use of emergency medical services and other costly health care services. The newly developed long-term goal quantifies the impact of stable PCCs on inappropriate/unnecessary health care services.

Evidence: See "Measures" Tab

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

Explanation: The program has established ambitious targets and timeframes for the program's long-term performance goal, which is to reduce emergency room visits due to poisoning by 25 percent by 2009.

Evidence: See "Measures" Tab

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

Explanation: For the FY 2006 PART, the program developed an efficiency goal that measures the time burden of grantees in the grant application process. HRSA's Maternal and Child Health Bureau anticipates implementing a new web-based grant application system by the end of FY 2004 to streamline the grant application process.

Evidence: See "Measures" Tab

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

Explanation: Baselines and ambitious targets have been established for annual performance measures that support the long-term output goal for the program.

Evidence: See "Measures" Tab

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

Explanation: The program partners are the PCCs, AAPCC and other organizations. The primary Federal entity is the Centers for Disease Control and Prevention. PCCs commit to the goals by working to establish the toll-free number, developing guidelines and staffing the Centers. Also, the Pacific Institute for Research and Evaluation (PIRE) provides technical assistance to PCCs to help them work towards achieving program goals. The resource center provides technical assistance during site visits, and interacts and collaborates with regional and national groups and stakeholder organizations and agencies. Services include grant writing, strategic planning, and strategic management.

Evidence: Evidence AAPCCs cooperative agreement

Are independent 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: Independent evaluations of sufficient scope are conducted on a regular basis to support program improvements and to evaluate the effectiveness and relevance of the program to the problem. HRSA's program was first established in 2000. In September 2001, the program awarded a contract to Battelle to evaluate the effectiveness of the stabilization component of the PCCs program. The report was completed in March 2002. The second focus of the Battelle contract was to assess the PCCs overall program. In addition, in September 2002, a contract was awarded to the Institute of Medicine to evaluate the future of PCCs. Both reports were completed in Spring 2004.

Evidence: Evidence 1. Battelle, Centers for Public Health Research and Evaluation - Evaluation of the Effectiveness of the Poison Control Centers Grant Program (March 24, 2004) 2. Institute of Medicine - Forging a Poison Prevention and Control System (April 2004)

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: The program does not provide a presentation that makes clear the impact of funding, policy or legislative decisions on expected performance nor does it explain why a particular funding level/performance result is the most appropriate.

Evidence: Evidence Congressional Justification submitted each February with the President's Budget

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

Explanation: To date, HHS/HRSA has not tied its budget requests to the accomplishments of the annual and long-term performance goals. HHS does plan to submit a performance-based budget beginning in FY 2006, but is it unclear whether this budget will show the marginal impact of funding decisions.

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: The program does not regularly receive timely and credible performance information from key program partners and use it to mage the program. HRSA does not receive any data at HRSA. All performance information is submitted to the AAPCCs who upload data from the PCCs every few minutes at AAPCC. Each PCC has a database that allows it to submit changes to the AAPCC. The AAPCC analyzes new data and makes it available in an annual report. The AAPCC must receive an official request from HRSA to receive updated data prior to the release of the annual report.

Evidence: Evidence Institute of Medicine - Forging a Poison Prevention and Control System (April 2004)

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: Federal managers for the PCCs program are officers in the Public Health Service Commission Corps. Commission Corps members receive a standard annual performance evaluation. While the performance of the PCCs can be considered in the evaluation of the Program Director and supervising Division Director, evaluations do not explicitly consider the management oversight of the program's performance, costs, and schedule. The program's GPRA goals are not required to be considered as part of the Federal managers' formal performance assessment. Beginning in FY 2004, the Office of Performance Review (OPR) will begin assessing grantees' performance through systematic pre-site and on-site analysis, using the Performance Review Protocol. The OPR will work with grantees to measure program performance, analyze the factors impacting performance and identify strategies and partnerships to improve program performance, with a particular focus on outcomes. OPR will also provide direct feedback to the agencies about the impact of HRSA policies on program implementation and performance within the communities and States. From this analysis and feedback, OPR will track key program performance issues, identify innovative practices and model programs, and when appropriate, develop recommendations for changes to current HRSA policies to further enhance the performance of HRSA-funded programs.

Evidence: Evidence Commission Corps Annual Performance Assessment

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

Explanation: Notices of Grant Awards are sent to grantees one month before the beginning of each budget period. The HRSA Grants Management Office receives financial status reports and most other reports required by the terms and conditions of the grant. A cost analysis is performed for every grant application approved for funding. The analysis involves obtaining cost breakdowns, verifying cost data, evaluating specific elements of cost, and examining cost data to determine necessity, reasonableness, and permissibility. OPR's assessments of activity are done continuously, with assistance from the Technical Resource Contractor who provides early warning notices.

Evidence: Evidence Financial Status Reports

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

Explanation: The program is developing procedures to measure and achieve efficiencies and cost effectiveness in program execution. EMSC grant applications are currently paper-based. HRSA's Maternal and Child Health (MCH) Bureau is in the process of implementing a web-based grant application system, which will be completed by the end of FY 2004. The program is also in discussion with AAPCC to ensure performance data on PCCs are available on a Federal, comprehensive website where the public can access all data pertaining to the program. In addition, the program out sources technical assistance through a cooperative agreement with the AAPCC.

Evidence: Evidence 1. AAPCCs cooperative agreement 2. Beginning in September 2004, all MCH Bureau applications will be web-based.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The program convenes a group of representatives of related national organizations who have a stake in the services provided by the PCCs. These stakeholders meet once or twice annually and have provided recommendations to the program regarding the initiation of activities to support PCCs and use of Federal support. These recommendations have guided program decisions on such activities as grant funding distribution methodology, grantee program participation requirements, program assistance for continuing education activities, and others. The stakeholder group is also scheduled to reconvene in July 2004 to assist in the creation of a strategic plan for future activities for the program. Additionally, the PCCs collaborate with the CDC on the nation-wide toll-free number to access PCCs and the media campaign associated with this telephone number. HRSA and CDC also work collaboratively on efforts related to the enhancement of the Toxic Exposure Surveillance System.

Evidence:  

Does the program use strong financial management practices?

Explanation: In FY 2003, HHS OIG conducted an HHS financial statement audit. The audit reported that the Department had serious internal control weaknesses in its financial systems and processes for producing financial statements. OIG considered this weakness to be material. The audit recommended that HHS improve their reconciliations, financial analysis, and other key controls. The September 30, 2002 HRSA independent auditor's report found that the preparation and analysis of financial statements was manually intensive and consumed resources that could be spent on analysis and research of unusual accounting. The audit also found that HRSA's interagency grant funding agreement transactions were recorded manually and were inconsistent with other agencies' procedures. Finally, the audit found that HRSA had not developed a disaster recovery and security plan for its data centers.

Evidence: Evidence 1. HRSA - Annual Report (FY 2002) 2. HHS Performance and Accountability Report (FY 2003)

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

Explanation: HHS' long-term strategic plan is to resolve the internal control weaknesses is to replace existing accounting systems and other financial systems within HHS with the Unified Financial Management System (UFMS). HHS plans to fully implement the UFMS Department-wide by 2007. HRSA developed a corrective action plan to address the reportable conditions identified in the September 30, 2002 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. The program is developing a new efficiency measure during the PART process. HRSA's Maternal and Child Health Bureau anticipates implementing a new, on-line, web-based system for all discretionary grant programs (non-block grant) before the end of FY 2004. This system will be used by all discretionary grantees in submission of their applications and in the reporting of financial and program performance data. The program anticipates that this system will greatly reduce the application and reporting burden for grantees. In addition, the program is working with AAPCC to encourage more public access to the data of the PCCs. Also, the program is developing a new efficiency measure during the PART process. HRSA's Maternal Child Health Bureau anticipates implementing a new, on-line, web-based system for all discretionary grant programs (non-block grant) before the end of FY 2004. This system will be used by all discretionary grantees in submission of their applications and in the reporting of financial and program performance data.

Evidence: Evidence Beginning in September 2004, all MCH Bureau applications will be web-based.

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

Explanation: Performance Review. In addition, grantees are required to provide annual progress reports. The progress reports include: 1) a brief summary of overall project accomplishments during the reporting period, including any barriers to progress that have been encountered and strategies/steps taken to overcome them; 2) progress on specific goals and objectives as outlined in the continuation grant application and revised in consultation with the Federal project officer; 3) current staffing, including the roles and responsibilities of each staff and a discussion of any difficulties in hiring or retaining staff; 4) technical assistance needs; 5) a description of linkages that have been established with other programs; and 6) a report on the status of and ongoing results of all project evaluation activities, including those relevant to process and outcome evaluations.

Evidence:  

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: Data are collected, but historically, have not been readily available to the public. The program is working with the AAPCC to research the development of a public web-site which would render this activity feasible. The target development date for this is early FY 2005. The AAPCC data collection system is proprietary and the Federal government has little leverage in requiring the AAPCC to make the data readily available.

Evidence:  

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

Explanation: The program has demonstrated progress toward achieving its long-term goal to reduce emergency room visits due to poisonings. The rate was 2.47 per 1,000 in 1999-2000 and the rate in 2001-2002 fell to 2.05 per 1,000.

Evidence: See Questions 2.1-2.2

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

Explanation: The program has demonstrated progress toward achieving its annual goals to increase inbound volume on the toll-free line (from 24.6% in 2002 to 36.9% in 2003), increase the number of PCCs with 24 hour bilingual staff (from 0 in 2003 to 1 in 2004), and increase the number of evidence-based guidelines for the treatment of toxic poisonings (from 1 in 2003 to 3 in 2004).

Evidence: See Questions 2.3-2.4

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

Explanation: During the PART process, the program developed an efficiency measure. HRSA's Maternal and Child Health Bureau anticipates implementing a new web-based grant application system by the end of FY 2004 to streamline the grant application process. Once the system is in place, the program will be able to track progress towards the new efficiency measure.

Evidence:  

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

Explanation: No other programs compare to the Poison Control Centers Program. Other programs focus on the prevention of poisoning, while HRSA ensures that if a poisoning occurs or is suspected, individuals have access to immediate medical advice.

Evidence: See Question 1.3

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

Explanation: Evaluations indicate that the program is effectively achieving results, but that improvements may be made as well. The March 2004 Battelle evaluation looked at: whether PCCs have made improvements in: 1) information systems and telecommunications capabilities, 2) financial stability, and 3) hiring and retaining staff, and 4) increased access to PCCs services. The evaluation found: 1) the majority of grantees planned to use grant funds to upgrade computer hardware (76%) and telecommunications equipment (52%), 2) the number of facilities that reported being in danger of closing increased from 5 percent in 2000 to 13 percent in 2002--many states reported an average loss of state funding by 46 percent, 3) hiring and retaining technically qualified staff remains problematic for PCCs, and 4) several PCCs reported using their grant to restore, maintain, or establish 24-hour service or to provide or improve services to special populations. The April 2004 IOM evaluation highlighted what the IOM would consider to be an ideal 'Poison Prevention and Control System'. It found that a regional network of PCCs will 'satisfy the need to distribute medical toxicological leadership across the United States to address the diversity of poison exposures and to provide firsthand consultant hospitals and physicians'. Other findings indicate that PCCs should have a core set of activities, HHS and States should integrate PCCs with public health agencies and ensure infrastructure in the event of a bioterrorism or chemical terrorism event, HHS should ensure exposure surveillance data are generated and available, and federally funded research should be provided.

Evidence: Evidence 1. Battelle, Centers for Public Health Research and Evaluation - Evaluation of the Effectiveness of the Poison Control Centers Grant Program (March 24, 2004) 2. Institute of Medicine - Forging a Poison Prevention and Control System (April 2004)