Detailed Information on the
Birth Defects and Developmental Disabilities Assessment

Explicitly tying budget requests to the accomplishment of annual and long-term goals, and present resource needs in a complete and transparent manner.

Demonstrate adequate progress in achieving the program's long-term performance goals.

Take steps to improve the program so that future independent evaluations indicate that the program is effective and achieving results.

Measure: Increase the sensitivity of birth defects and developmental disabilities monitoring data.

Explanation:The program bases its model surveillance systems on the same methodology; however, the birth defects system is more mature and thus able to be assessed numerically. Investments are needed to be able to measure the same for developmental disabilities (a study was developed in 2004 and initiated in 2005) and we project baseline data to be available for this measure by 2008. For birth defects, the number offered is a measure of sensitivity, that is, the likelihood that a case identified by the system is in fact a true birth defect case. For developmental disabilities, the measure is initially based on establishing the baseline probability that a true developmental disability is identified by the program's model birth defects system. Because the nature of the program's work is surveillance, this approximates their ultimate outcome of improving infant health. Accurate birth defects monitoring data is important for several reasons. First, it tells CDC what is going on in the population, and enables research to be focused on important or emerging public health issues. For example, birth defects monitoring helped to indicate that there was a need for further research on congenital heart defects. Second, it assists in planning prevention and intervention programs, and evaluates their effectiveness. MACDP helped to demonstrate the effectiveness of folic acid fortification by showing a decrease in neural tube defects after cereal grains were fortified with 140 micrograms of folic acid. Third, it helps to project the need for health care services, especially when a condition is potentially disabling or requires special services.

Measure: Identify and evaluate the role of at least five new factors for birth defects and developmental disabilities.

Explanation:Understanding the role of modifiable risk and preventive factors in the etiology of birth defects and developmental disabilities provides an important opportunity for prevention. As prior investments in the research infrastructure for birth defects is more mature, initial efforts annual performance measures focus on publication of research findings from this system. Meanwhile, the infrastructure for research on autism and other developmental disabilities research is being established. This research infrastructure follows the same model as that for birth defects but is in the early stages of development, with initial publication of findings expected in 2012.

Measure: Reduce health disparities in the occurrence of folic acid-preventable spina bifida and anencephaly by reducing the birth prevalence of these conditions among Hispanics.

Explanation:Pregnancies and births affected by spina bifida and anencephaly have profound physical, emotional, and financial effects on families and communities. Since food fortification in 1998, thousands of babies are being born in the U.S. without these serious birth defects. However, analyses by racial and ethnic groups found that while fortification lowered rates significantly among all racial and ethnic groups, that a disparity with respect to Hispanics has persisted. The program is currently focusing on developing and implementing evidence-based strategies to reduce the occurrence of these birth defects among Hispanics. Program targets are based on the concept of diminishing returns, the understanding that preventing the first cases is easier than preventing latter cases. From 1996-2000, rates declined by 36%. As it becomes more and more difficult to prevent cases that existing strategies have not been able to reach, more intensive efforts are required to achieve the same level of reductions. Thus, for the next 5 year period (2001-2005), targets were set based on a proposed 18% decline in rates (1/2 of 36%). Similarly, for the subsequent 5 years (2006-2010), the program has set targets based on a proposed decline of an additional 9% (1/2 of 18%) in rates from 2005. If the program is successful in meeting these targets, a more than 50% decline in spina bifida and anencephaly will have been achieved over the span of 15 years.

Measure: Increase the percentage of health providers who screen women of childbearing age for risk of an alcohol-exposed pregancy and provide appropriate, evidence-based interventions for those at risk.

Explanation:This is an intermediate outcome as it reflects a change in health care provider practices. Implementing intervention strategies to reduce alcohol consumption during pregnancy is an important component of reducing the occurrence of alcohol-related birth defects and developmental disabilities, including Fetal Alcohol Syndrome (FAS). Research shows that: 1) provider-based screening of women of childbearing age at risk of having an alcohol-exposed pregnancy; and 2) provider-based interventions for women at risk are effective strategies for reducing alcohol-exposed pregnancies. CDC has begun to translate research findings through the development and publication of targeted recommendations on provider-based screening and interventions for women of childbearing age.The program is currently working to establish base-line rates of screening from a population-based sample of health care providers and anticipates setting the base-line during the next reporting year. Following that, the program will be able to set performance measures. In the absence of population-based information on screening practices, an improvement of 1% a year may represent ambitious benchmarks. Once the program establishes a baseline and measures changes over time, it may be appropriate to revisit targets.

Measure: Increase the number of people with blood disorders who participate in the monitoring system by 10%.

Explanation:Because hemophilia patients are the largest users of blood products, products are monitored through the UDC for any infectious agents and early identification of possible transmission of blood borne infection can be decreased. Increasing the number of patients enrolled in the UDC is important to ensure that the majority of patients with bleeding disorders are monitored, so that complications due to the underlying bleeding disorder and other risk factors may be assessed on a population level.??

Measure: Ensure that 95% of all infants are screened for hearing loss by 1 month of age

Explanation:The nature of this program is surveillance and as such this measure serves as an intermediate outcome of ameliorating the effects of hearing loss. Infants identified with hearing loss can be refeared in a timely manner to an early intervention programs or have other interventions (mechanical or surgical) to improve the child's skills in coping with hearing loss. Early intervention programs are designed to help infants and children develop communication skills needed to do well academically and socially. Communication skills can be learned through visual language, spoken language, or both. There is a 2 year data reporting lag.

Measure: Increase the mean lifespan of patients with DBMD and carriers by 10% as measured by the Muscular Dystrophy Surveillance, Tracking and Research Network.

Explanation: CDC is engaged in the development of a population-based monitoring system designed to ascertain key health information for people with Muscular Dystrophy (MD). This system, MD STARnet, is the only source of epidemiologic data necessary to engage in intervention research. Annual goals are set to document progress towards the health outcome. These ambitious benchmarks reflect essential steps in the public health process: public health surveillance, epidemiologic research, and intervention development and delivery. The benchmarks outline the process of developing and implementing a comprehensive surveillance system, which will provide population-based data. Analysis of this data will be used to inform a comprehensive approach for care of individuals who have DBMD. Following development and dissemination of the DMD care considerations, data from MD STARnet will be used to assess variations in treatments and outcomes. It is expected that earlier diagnosis and improved treatment should have a positive effect on lifespan. As the study has progressed, improvements to the abstraction tool have been implemented to widen the scope of surveillance. Preliminary data analysis has confirmed variability in care among individuals who have DBMD and generated more hypotheses and research questions.

Measure: Identify an effective public health intervention to ameliorate the effects of poverty on the health and well-being of children

Explanation:This serves as a proxy measure because the nature of the program is research. Healthy children are more ready to learn and are more likely to become healthy adults who will be productive members of society. Children who grow up in environments where developmental needs are not met are at an increased risk for compromised health and safety and learning and developmental delays. In addition, it has been demonstrated that adults who were exposed to four or more adverse childhood events were at higher risk for alcoholism, drug abuse, depression, suicide attempt, smoking, poor self-rated health, multiple sexual partners, STDs, physical inactivity, and obesity. In response, CDC focused on developing an innovative public health intervention to promote protective factors and ameliorate risk factors impacting developmental outcomes.

Measure: Increase the percentage of cost savings for the Coordinating Center for Health Promotion (CCHP) as a result of the Public Health Integrated Business Services High Performing Organization.

Explanation:CDC is undergoing an agency-wide five year process to achieve significant efficiencies through the Public Health Integrated Business Services High Performing Organization (PHIBS HPO). The focus of the PHIBS HPO is to systematically improve and modernize 16 different business support services reaching optimal efficiencies in service quality and at the same time reducing staff resource costs that perform the services by 2011. These include payroll, travel, committee management, facilities, staff training, acquisition support, extramural activities, conference planning, secretarial support, property, records management, personnel, business information systems support, funds management assistance, FOIA and IG/GAO processing and cost recovery. Ultimately, the HPO will affect 2,000 FTE's agency-wide, almost 22% of CDC's workforce. The Coordinating Center for Health Promotion, of which the National Center for Birth Defects and Developmental Disabilities is a constituent organization, underwent the first phase of consolidation in 2007. The targets are to be considered ambitious in light of the administrative effort required in moving personnel from 16 different business services and creating or rewriting standard operating procedures. Processing personnel actions challenges the human resources system, which is already fully engaged in its routine efforts of hiring, etc. Additionally, the HPO efforts are occurring in addition to the routine daily activities by management officials required to continue the work of the agency. The FY 2007 result of 28.4% savings actually represents an approximate savings of $6.2 million for the Coordinating Center. The FY 2009 target projects a slight reduction due to the two additional business services that are being consolidated or reorganized in FY 2009, for which efficiencies will not be realized during this same year.

Is the program purpose clear?

Explanation: The purpose of the CDC's National Center on Birth Defects and Developmental Disabilities (NCBDDD) is to promote the health of babies, children, and adults, and to enhance the potential for full and productive living. The program focuses on identifying the causes of and preventing birth defects and developmental disabilities, helping children to develop and reach their full potential, and promoting health and well-being among people of all ages with disabilities. The mission of the program is clear.

Evidence: Evidence includes the program mission statement, appropriations history, and the Center's Report to Congress 2003-2004, the updated information on the Center's activities and progress. Evidence also includes Public Health Service Act authorization (P.L. 106-310) from the Children's Health Act of 2000 establishing the National Center on Birth Defects and Developmental Disabilities, and the Birth Defects and Developmental Disabilities Prevention Act of 2003, which further clarified the mission of the Center.

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

Explanation: The program addresses specific public health problems in the areas of birth defects, developmental disabilities, and health for people living with these and other disabilities, including inherited blood disorders. The public health burden of these conditions is substantial. The number of people living with birth defects, developmental disabilities, or acquired disabilities is rising and is expected to increase over the next decade.

Evidence: Birth defects are the leading cause of infant mortality in the United States, and the economic cost of caring for children and adults with birth defects exceeds $8 billion per year. Approximately 17% of U.S. children have a developmental disability such as mental retardation or autism. At least 54 million Americans are currently experiencing a physical, cognitive, or sensory limitation, and an annual economic cost of $300 billion is associated with these disabling conditions. In addition, the specific disabilities associated with bleeding and clotting disorders affect millions of Americans, including the 1-2% of women with a bleeding disorder, the 5%-8% of Americans with a clotting disorder, and the thousands living with hemophilia. Sources of data include documents available on the program's website (http://www.cdc.gov) including Disability and Health in 2005 and the Report to Congress 2003-2004.

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

Explanation: Although numerous public and private organizations work on some facet of birth defects and disabilities, the program applies public health methods and practices to the prevention of these conditions through intensive monitoring and application of epidemiologic methods to investigate potential causes of these conditions. The program's work provides an important basis used to develop prevention and intervention strategies, which are then implemented both by the program and other stakeholders, including states, localities and other organizations. The program provides the coherent public health response to disability by addressing the health promotion needs of the 54 million Americans living with a disability.

Evidence: The program is the only organization providing financial and technical assistance to states to develop and implement programs necessary to improve the health of this population. On a broader level, the program informs the overall response to disability. For example, the program worked closely with the Office of the Surgeon General to develop the first ever U.S. Surgeon General's Call to Action to Improve the Health and Wellness of Persons with Disability 2005. The program utilizes public health methods including monitoring (or surveillance), epidemiologic research, and prevention and intervention development to use in addressing these issues. For example, as part of the Interagency Autism Coordinating Committee, the program's role in addressing the many questions surrounding autism includes being the designated source for population-based data on the true prevalence of this condition. A research matrix developed by this committee demonstrates that there are differences in the role each federal agency has in responding to the issue of autism and also how these agencies work together to serve the public. Similarly, as a result of strategic planning, the program has developed and is executing a federal agency engagement plan to further ensure that our efforts are complementary with those of other agencies. Engaging with outside organizations helps ensure that the program's response is addressing real public needs and contributes to ensuring that its resources are used most efficiently.

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

Explanation: There is no evidence of major design flaws that limit the program's efficiency or effectiveness. The program follows proven public health methods based on monitoring, research, prevention, and intervening across the lifespan. While the program conducts the monitoring, research, and prevention activities needed, the program is also concerned with protecting the health of children and adults already affected by birth defects or other disabilities. Public health methods are utilized in monitoring the health of affected individuals, conducting research into causes of complications, and designing interventions to improve the health of affected individuals. By having the public health response for these conditions coordinated across the lifespan, efficiencies are more readily achieved.

Evidence: The program's activities to promote folic acid provide an example of an effective application of this model to achieve positive health outcomes. First, birth defects monitoring (also known as surveillance) documented a public health burden with respect to disabling and often fatal birth defects of the neural tube. Public health research identified that the B vitamin folic acid, if taken before and during early pregnancy, could prevent the majority of such defects. Thus, the public health approach, once armed with the knowledge that folic acid prevented certain birth defects, was to develop and implement prevention strategies to increase folic acid consumption among women of childbearing age. Since effective implementation of successful strategies, birth defects monitoring systems have documented a significant decline in the occurrence of these conditions. The program continues to explore additional prevention strategies to further reduce the occurrence of folic acid-preventable defects. This model demonstrates the overall design of our public health approach to preventing birth defects and disabilities and the complications associated with them.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: The program targets state, local, and tribal health departments, other federal agencies, community-based organizations, professional associations, academia, clinical settings, and international organizations. The program implements a rigorous, merit-based review process based on scoring of stated criteria for all applications for federal assistance. The program regularly monitors the progress of established grantees in pursuit of public health goals and provides ongoing guidance in the form of site visits and other regular communications. Use of cooperative agreements allows for needed collaboration and guidance, and enhances efficiency and opportunities for a more consistent and standardized approach. The program also develops and maintains model programs and assists states in emulating these programs through published guidelines outlining effective methods. The program also serves as a resource for entities that do not receive financial support, such as states working to increase capacity to conduct birth defects monitoring.

Evidence: The program follows accepted standardized methods in evaluating the merit of applications for federal assistance, ensuring that resources are being used effectively to meet the program's purpose. Also, the program funding announcements in the Federal Register very clearly state that measurable outcomes must be achieved with program funding, consistent with the performance goals established by the program. The program also published guidelines and model practices for implementing the monitoring, research, intervention, and prevention of birth defects and developmental disabilities, designed to improve the quality and usefulness of data to ensure appropriate diagnosis and treatment.

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 has recently completed its first-ever strategic planning process. Through this process, the program identified two long-term goals: 1) prevent or reduce birth defects and developmental disabilities; and 2) improve the health and optimal development of all people with disabilities or potentially disabling conditions. In support of these goals, the program has developed a limited number of long-term performance measures that specifically target the wide range of activities and programs. The measures have been included in a model that describes the program's key activities and how program activities contribute to the achievement of the long-term public health goals outlined above. The activities for both goals follow the public health framework of 1) monitoring to track rates, identify disparities, and identify clues to pursue through research; 2) research to identify risk and protective factors; and 3) work to implement evidence-based prevention and intervention strategies.

Evidence: The long-term measures include to improve the sensitivity of birth defect and developmental disability monitoring data, reduce the prevalence of spina bifida and anencephaly in Hispanics, and increase infant hearing loss screening rates.

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

Explanation: The program has challenging but realistic quantifiable targets and timeframes for the long-term outcome measures.

Evidence: The targets include a 27 percent decrease in spina bifida and anencephaly rates in Hispanics from 2000 to 2011. Achievement of this goal will be challenging, and will require significant outreach to the Hispanic community. The targets also include a seven percent increase in newborn infant hearing loss screening rates by supporting State-based efforts to promote screenings.

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: The program has established a limited number of annual performance measures that are intended to ensure accountability for the program as it works towards the achievement of the long-term outcome goals.

Evidence: The measures include annual performance improvements towards reaching several of the long-term outcome goals, with annual quantitative benchmarks. Included in these annual measures are reductions in spina bifida and anencephaly rates in Hispanics, and increases in newborn hearing loss screening rates.

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

Explanation: The program has established base-lines and ambitious targets for each of its annual measures. These annual performance measures are linked to the program's long-term measures and also support the program's long-term goals.

Evidence: The targets include annual reductions in spina bifida and anencephaly rates in Hispanics and annual increases in newborn hearing loss screening rates.

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 requires grantees to work toward achievement of long-term goals and measures. Prior to the development of the strategic plan, the program utilized Federal and Department measures including the Government Performance and Results Act (GPRA) and Healthy People 2010 to ensure partners were committed to and supportive of the intent of the program.

Evidence: RFAs for grant funding very clearly state that grantees must track measurable outcomes that are consistent with the programs performance goals. The program will add the new measures and targets to the grants process. Federal Register Notices will state the appropriate goal/measure/target the grantee must achieve. Grant applications will include scoring on the grantees' ability to achieve desired results. The program will work with partners on meeting these goals, targets and measures through incentives and changes in funding levels.

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: The program has had multiple independent evaluations conducted to evaluate effectiveness. In addition, the program has convened external peer review panels for several of the program's components, and has plans to do so for all program areas by the end of the 2006 fiscal year. These portfolio reviews included review of scientific and programmatic activities as well as intramural and extramural research activities of each program. Final evaluation reports from these reviews include recommendations to increase effectiveness and relevance of its activities. In addition to these portfolio reviews, several program components have been the subjects of additional evaluations.

Evidence: In outlining next steps for addressing autism, the Institute of Medicine has issued independent recommendations regarding surveillance and epidemiological research. In addition, a GAO review of the Federal government's response to autism, including this program's activities, is currently underway. Finally, the program's Early Hearing Detection and Intervention team is funding an independent evaluation to identify strategies to assist the team in meeting one of its goals.

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 has made progress in integrating performance and budget. However, the relationship between performance and budget levels is not clearly defined. The program does not quantify or estimate how changes in funding levels could impact performance levels.

Evidence: Evidence includes the GPRA plans and reports and annual Congressional Justification and budget documents provided to OMB.

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

Explanation: The agency is taking a comprehensive effort to integrate budget and performance agency-wide. In addition, the program now has a strategic plan from which a limited number of long-term goals and annual targets have been developed. This strategic plan was developed to be in alignment with agency-level goals. These long-term measures will provide the foundation for future funding decisions, including holding grantees accountable for moving the program towards these measures. Moreover, the plan itself contains a detailed map for program progress towards meeting its goals, and it contains internal control measures to ensure semi-annual review of progress toward the goals and objectives contained within the plan. Program divisions and teams are required to report to the Office of the Director on their progress toward their goals and objectives at the end of the second quarter of the fiscal year. At the end of the year, they are required to provide a formal presentation on their progress and provide recommended modifications to the strategic plan.

Evidence: Evidence includes the annual budget submissions to OMB and Congress, and documentation from the program on the new strategic plan and performance goals.

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's funding mechanism of choice is cooperative agreements. Cooperative agreements allow the program to work constructively with grantees and partners in the design and implementation of projects and to closely monitor grantee performance. All grantees are also required to complete mid-year and final annual reports that document progress toward achievement of intended targets and program goals. Grantee performance information is collected through systematic and ongoing communications including site-visits, semi-annual reports, conference calls and grantee meetings (reverse site visits). Site visits are conducted at least once per year per grantee to ensure the proposed projects are meeting intended goals and targets. During these visits, project officers collect information on grantee performance and overall project management. A site-visit report is generated to provide written feedback to the grantee regarding recommendations for program improvements or changes in direction. When necessary, the project officer communicates corrective action steps to the grantee in writing via report comments and site-visit reports.

Evidence: Sources include performance information obtained through progress reports from grantees that measure progress relative to performance targets. Evidence also includes site visit reports that describe a project officer's evaluation of a grantee project and includes recommendations for improvements.

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: Accountability for cost, schedule and specific outputs are established through performance appraisals for program managers. Program managers (i.e. team leads) are held accountable for program results. Senior managers (directors) have elements of accountability built into performance evaluation systems, including for the commissioned Corps, and employees now incorporate one or more general performance measures from the agency or department level into their work plans. Contractors are also held accountable for cost, schedule and performance results.

Evidence: Evidence includes employee performance plans that contain evaluation standards, and financial status reports hat track grantee project expenditures. The program works with cooperative agreement recipients to establish a baseline budget for the approved activities. Grantees are required to report on program progress through regular communications with program staff and formally through periodic and annual progress reports. Financial status reports are due within 90 days after the budget cycle ends for review. For each contract, the contractors agree to submit deliverables / products by specified deadlines. Contractors must submit monthly invoices, and the invoices are reviewed by the program technical monitor for accuracy. Inaccurate invoices are returned to the contractor for correction prior to payment. The technical monitors recommend approval of payment for all invoices.

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

Explanation: Funds are obligated in a timely manner and spent for the intended purposes. CDC's Financial Management Office (FMO) ensures that appropriated funds are properly obligated in a timely manner and that mechanisms are in place to ensure that funds are spent for the purpose for which they are intended. The creation of CDC goals action plans will lay out our measurable objectives and specific activities that will result in progress toward achieving public health impact. Aligned to these efforts will be the execution spending plans. The spending plans provide CDC with a detailed sketch of CDC estimated resources needed for the fiscal year by quarter. Each plan is then used to control the incurrence of obligations and is subject to strict fund control procedures. Reviews indicate that the agency successfully prevents erroneous payments.

Evidence: Evidence includes standard operating procedures of the budget execution branch at CDC, which explains efforts to ensure that spending plans are executes properly and support agency goals. Spending plans developed at the program level also serve as evidence. The spending plans are used to certify and monitor the status of funds at the program and agency level. Status of funds reports display the funds allotted to the program, and list obligations, commitments, and unobligated balances. CDC uses this information to monitor obligation rates and potential variances. Risk assessments were completed to determine whether they were susceptible to improper payments exceeding $10 million and a 2.5 percent error rate and required to estimate improper payments under the Improper Payments Information Act of 2002 (IPIA) and the related OMB Guidance.

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 has an efficiency measure of the amount of time it takes the program to complete the grant award process, aiming to get funding to recipients more quickly. CDC continues to examine agency operations to identify areas where efficiencies may be realized. In addition to competitive sourcing studies to meet the requirements of the President's Management Agenda, CDC has reviewed and reorganized its organizational and reporting structure. Further efforts to increase efficiencies include two restructuring initiatives, covering administrative and business service functions. Goals of restructuring these functions include alignment with and support of CDC's new organizational structure, as well as targeting greater efficiencies through process improvements and standardization across the agency. CDC has completed de-layering the agency to no more than four management layers.

Evidence: CDC has completed several competitive sourcing studies over the past three years, covering such services as Animal Care, Facilities Planning and Management, Library Services, Statistical Support, and Writer/Editor functions. CDC has won 13 of the 14 studies completed. Savings realized from competitive sourcing are reinvested in mission-direct public health activities. With the elimination of over 200 "sections", a 33% decrease in the official number of organizational units since 2001 has been achieved. Additionally, CDC's supervisory ratio has more than doubled from 1:5.5 in 2002 to over 1:12.6 in January 2006.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The program collaborates with other federal and non-federal partners to ensure a coordinated response to the complex issues under their mission. Through their participation in numerous interagency committees and task forces, the program works to prevent redundancy and promote synergy. The program coordinates with other parts of CDC and with partner organizations. A set of national recommendations were developed and published. Finally, the program works closely with private organizations through the External Partners Group, a body of more than 300 organizations working to address the complications of or to prevent birth defects and disabilities.

Evidence: The program helps to ensure a coordinated federal response to autism through their participation on the Interagency Autism Coordinating Committee. The program has also coordinates efforts through the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effects. Program staff worked closely with the Office of the Surgeon General to develop the first ever U.S. Surgeon General's Call to Action to Improve the Health and Wellness of Persons with Disability 2005. The program formalized their collaboration with NIH / National Center for Medical Rehabilitation Research (NCMRR) and the Department of Education / National Institute on Disability and Rehabilitation Research (NIDRR) to jointly fund a $1.2M task order contract in support of an IOM report to review the principles and scientific evidence for disability policies and services.

Does the program use strong financial management practices?

Explanation: In April 2005, CDC implemented a new Unified Financial Management System (UFMS). UFMS is an integrated, Department-wide financial system that consistently produces relevant, reliable, and timely financial information to support decision-making and cost-effective business operations at all levels throughout the Department. UFMS replaced the legacy mainframe-based financial system, which was over 15 years old. UFMS provides the program with more real-time financial data, improved financial reports that allow managers to make timely decisions, and streamlined financial processes. UFMS will help the Department continue to achieve unqualified audit opinions. The HHS FY 2005 Performance and Accountability Report noted a material weakness related to the transition to UFMS, but full implementation will eliminate this material weakness.

Evidence: Evidence includes the HHS Performance and Accountability Report. The report stated that system implementations frequently create data conversion and other issues that can lead to difficulties in processing transactions appropriately and preparing accurate reports, and constitute a risk over the next several years. In the interim, substantial "work-arounds," cumbersome reconciliation and consolidation processes, and significant adjustments to reconcile subsidiary records to reported balances have been necessary under the existing systems. Specifically, the report stated UFMS could not produce financial statements, and therefore, CDC continued to use cumbersome processes to crosswalk the unadjusted trial balance to the financial statements increasing the risk of errors. UFMS implementation actively addresses the financial systems issue. CDC anticipates producing system-generated financial statements by the end of first quarter FY 2008 and reducing the manual processes and excessive efforts identified in the FY 2005 report. To date, CDC has implemented reviews, reconciliations, fluctuation analysis, and checks to ensure the accuracy and completeness of the financial statements. CDC has also streamlined the statement preparation outside the central financial system by using automated tools to expedite consolidating financial data.

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

Explanation: The program does not have any major management deficiencies. However, the program continues to take steps to improve any management deficiencies that may remain.

Evidence: The program will continue to monitor the performance of the new financial management system and the impact the system has on resolving weak nesses. The program recently transferred information technology currently being used by the National Center for Birth Defects and Developmental Disabilities to track investments made both in contracts and cooperative agreements. This system will allow the center to identify cycle times to process financial investments as well as quickly identify expiration, continuation, and cost benefit analysis of current investments. Another example of steps taken to address management deficiencies is in the internal controls system. OMB Circular 123 requires that investments be evaluated for vulnerability and susceptibility to fraud, waste, and abuse. The program has identified seven business areas that have the potential to fall victim to fraud, waste, and abuse. The program has conducted susceptibility and vulnerability analysis of these areas are in the process of conducting a process audit to confirm that policies are in place to avert any potential for fraud, waste, and abuse and to document that the policies are being followed.

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: The program ensures grants are awarded through a clear and competitive process by following the agency's Standard Operating Procedures on the preparation and publishing, evaluation and awarding of competitive grants as outlined by the Procurements and Grant Office. Review of grant applications are conducted through objective review panels. Prior to renewal, grantees must submit a new annual plan and budget for review by the project officer. A technical review is conducted to ensure that there is progress towards achieving the project's goals, expenditures of funds have been in accordance with the approved budget and that new activities are in alignment with the intent of the program. For research grants, the program utilizes the procedures that CDC employs to conduct peer review of influential scientific information and highly influential scientific assessments that CDC disseminates to the public. These procedures were developed in accordance with the White House Office of Management and Budget (OMB) "Final Information Quality Bulletin for Peer Review".

Evidence: Funding announcements are prepared in accordance with the Awarding Agency Grants Administration Manual (AAGAM) Chapter 2.02.102 and Chapter 2.03.103 and are reviewed by the Procurements and Grants office to ensure compliance with all appropriate regulations and sound business practices. Funding announcements are distributed through Federal Register Notices, EGrants.gov, FedSource, and other websites including the Program's internet site. In addition, the program uses a variety of listservs and meetings to announce funding opportunities to reach as many potential applicants as possible, including new and non-traditional organizations. This process involves the thorough and consistent examination of applications based on an unbiased evaluation of scientific or technical merit or other relevant aspects of the proposal. The grant review is performed by persons expert in the field of endeavor for which support is requested, and is intended to provide advice to the individuals responsible for making award decisions.

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

Explanation: Project officers, who oversee contracts, grants, and cooperative agreements for CDC, are required to take a Basic Project Officer training course and pass a written exam. The program provides oversight of grantee activities by requiring interim progress reports, financial status reports and final financial and performance reports of grantees. In the event that a grantee is not adequately performing, the program has several options. Often the program will increase the intensity of monitoring through regular conference calls to provide technical assistance and ensure the grantee makes corrective actions to address the issue or concern. The program can restrict the use of funds until the grantee has addressed a specific concern. If performance does not improve, the program has the ability to deny a request for funding renewal.

Evidence: Grantee oversight information includes detailed information on programmatic activities and progress towards goals and objectives. Technical reviews are conducted on an annual basis prior to the renewal of funding. In addition, project officers are required to conduct at least one site visit per year. The program has developed Grantee Site Visit Reporting guidelines to facilitate the collection of information necessary to adequately monitor the programmatic activities of the grantees. The program has established a Standard Operating Procedure for reviewing and approving grantee requests to redirect funds or approve a change in activities that deviate from the original work plan. The program uses the Public Health Service Grants Policy Statement [DHHS Publication No. (OASH) 94-50,000 (Rev.) April 1, 1994]. The award and administration of financial assistance are subject to applicable laws, regulations, and policies.

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 grantee performance data. Performance information is aggregated at high and individual State level and made public on the agency's website through the GPRA performance reports. The program does provide educational materials, health studies, and grants information to the public on the internet and the public has access to the CDC information line for educational materials.

Evidence: Evidence includes the programs GPRA performance plans, which can be found online at (http://www.cdc.gov/od/perfplan/2004/2004perf.pdf.) . The program also makes performance information available at http://www.cdc.gov.

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

Explanation: As the program has created a new set of long-term performance goals this year, there is not sufficient data to indicate that there goals are currently being achieved. However, the program has shown progress towards the goal of reducing the rate of spina bifida and anencephaly rates in Hispanics since 2000.

Evidence: Performance information on long-term measures indicate success in making progress on this long-term outcome goal. This improvement has been reported by CDC in the MMWR, and in independent reviews.

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

Explanation: The program has demonstrated annual progress on a limited number of the new long-term outcome goals. In particular, the program has met benchmarks related to the identification of effective public health interventions to reduce the effects of poverty on the health of children. Once developed, these benchmarks will be used to craft activities targeted to this high-risk population. The program has also achieved benchmarks related to the increased screening of women at risk of alcohol-exposed pregnancy. These screenings are an important component of reducing the occurrence of alcohol-related birth defects.

Evidence: Performance information indicates success in making progress on annual performance goals. This improvement has been reported by CDC in the MMWR, and in independent reviews.

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

Explanation: The assessment of large extent reflects the adoption of a new efficiency measure and a wide range of efficiency enhancement at the agency in the past year. Examples of efficiency enhancements include: more than doubling CDC's supervisory ratio from 1:5.5 in 2002 to 1:12.6 in January 2006; completing several competitive sourcing studies from 2003 through 2005, with CDC winning 13 of 14 studies; consolidation of 13 IT infrastructure functions, services, staff and fiscal resources into the new Information Technology Services Office (ITSO), which reduced operating costs by 30% and staff by 29% and decreased costs from a baseline of $8,454 per user in 2003 to $6,157 per user for 2005; and, consolidation of multiple business services (budget execution, travel, graphics, and training).

Evidence: Evidence of these improved efficiencies can be found in the annual CDC Congressional Justification, in competitive sourcing studies, the Business Services Consolidation Plan, and the Business Consolidation Update.

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

Explanation: N/A

Evidence: There are no other federal programs that share the role of the program and the program's activities cannot be compared directly with other federal, state or private entities.

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

Explanation: The program receives evaluations that are sufficient in scope and quality, and these evaluations find positive results. However, the evaluations do not draw a clear link between the program and the results.

Evidence: An evaluation on vaccine safety by the Institute of Medicine validates the relevance, safety, and effectiveness of certain childhood vaccines, but does not draw a clear relationship of the actions of the program with the safety of the vaccine. A study published in the journal of the American Academy of Pediatrics found declining rates of spina bifida and anencephaly, but does not establish a relationship between the actions of the program and the decline rates.