Executive Summary

After a series of publicized animal deaths at the Smithsonian Institution’s National Zoological Park (National Zoo) in early 2003, Congress asked the National Academies to carry out a fast-track, science-based assessment of the quality and effectiveness of animal management and care at the National Zoo’s Rock Creek Park facility in downtown Washington DC and Conservation Research Center (CRC) in Front Royal, Virginia. Congress specifically requested that the Academies’ report be in two parts: an interim report to be completed within 6 months of the beginning of committee deliberations and a final report. The committee’s interim report, released on February 25, 2004, focused on problems in need of immediate attention in the areas of animal care and management, recordkeeping, pest control, and strategic planning. This final report examines whether the institution is responding adequately to concerns raised in the interim report and addresses other aspects of its task, such as strategic planning, human resources, training, and occupational health and safety.

The National Zoo has been through a year of substantial upheaval as it attempts to reverse a decade-long decline in facilities, animal collection, and quality of animal programs. Over the last 12 months, the committee interviewed all levels of zoo staff, examined copious documentation and internal correspondence, received input from concerned members of the public and zoo community, and spent many hours observing operations at the zoo. The committee was presented with persuasive evidence that the zoo has many strengths, including the quality of its science programs and the dedication of its staff. The committee commends the staff of the zoo for the time, energy, and personal commitment that have resulted in an enormous number of positive changes in a short amount of time and thanks the staff for their efforts in fulfilling the committee’s requests for documents, which required a substantial amount of staff time.

It is apparent to the committee that the zoo’s deterioration evident in the fall of 2003 was the result of long-standing, systemic problems at the highest levels of the zoo’s operations. Lack of overall vision, inattentiveness to American Zoo and Aquarium Association (AZA) and internal evaluations, and laxity in observing federal laws by the management of the zoo and Smithsonian Institution allowed for a system-wide breakdown in communications and responsibilities. This resulted in more than a decade of decline in almost every aspect of zoo operation, until a groundswell of change began in 2000. While some initial efforts at change may have faltered, continued efforts for change have gained momentum. The staff of the National Zoo must be applauded for their efforts that have resulted in noticeable improvement of zoo operations over the past year. Over the last 6 months, they have reorganized their preventive-medicine and nutrition programs and made substantial strides in developing an electronic keeper record system, centralizing their commissary, and establishing performance measures for all levels of the organization that are monitored by senior management. The committee encourages the staff of the National Zoo to continue in a positive direction towards regaining the National Zoo’s preeminence in the zoo community.

However, several problems need attention if positive changes to ensure animal health and welfare are to continue. These problems include immediate needs identified in the interim report as well as the recommendations made in this final report. Most pressing of these recommendations is the establishment of rigorous animal-care staff training as well as a climate of accountability and personal responsibility. Of equal importance are the completion of renovation or construction of animal facilities and the development of a complete and comprehensive strategic plan.



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Animal Care and Management at the National Zoo: Final Report Executive Summary After a series of publicized animal deaths at the Smithsonian Institution’s National Zoological Park (National Zoo) in early 2003, Congress asked the National Academies to carry out a fast-track, science-based assessment of the quality and effectiveness of animal management and care at the National Zoo’s Rock Creek Park facility in downtown Washington DC and Conservation Research Center (CRC) in Front Royal, Virginia. Congress specifically requested that the Academies’ report be in two parts: an interim report to be completed within 6 months of the beginning of committee deliberations and a final report. The committee’s interim report, released on February 25, 2004, focused on problems in need of immediate attention in the areas of animal care and management, recordkeeping, pest control, and strategic planning. This final report examines whether the institution is responding adequately to concerns raised in the interim report and addresses other aspects of its task, such as strategic planning, human resources, training, and occupational health and safety. The National Zoo has been through a year of substantial upheaval as it attempts to reverse a decade-long decline in facilities, animal collection, and quality of animal programs. Over the last 12 months, the committee interviewed all levels of zoo staff, examined copious documentation and internal correspondence, received input from concerned members of the public and zoo community, and spent many hours observing operations at the zoo. The committee was presented with persuasive evidence that the zoo has many strengths, including the quality of its science programs and the dedication of its staff. The committee commends the staff of the zoo for the time, energy, and personal commitment that have resulted in an enormous number of positive changes in a short amount of time and thanks the staff for their efforts in fulfilling the committee’s requests for documents, which required a substantial amount of staff time. It is apparent to the committee that the zoo’s deterioration evident in the fall of 2003 was the result of long-standing, systemic problems at the highest levels of the zoo’s operations. Lack of overall vision, inattentiveness to American Zoo and Aquarium Association (AZA) and internal evaluations, and laxity in observing federal laws by the management of the zoo and Smithsonian Institution allowed for a system-wide breakdown in communications and responsibilities. This resulted in more than a decade of decline in almost every aspect of zoo operation, until a groundswell of change began in 2000. While some initial efforts at change may have faltered, continued efforts for change have gained momentum. The staff of the National Zoo must be applauded for their efforts that have resulted in noticeable improvement of zoo operations over the past year. Over the last 6 months, they have reorganized their preventive-medicine and nutrition programs and made substantial strides in developing an electronic keeper record system, centralizing their commissary, and establishing performance measures for all levels of the organization that are monitored by senior management. The committee encourages the staff of the National Zoo to continue in a positive direction towards regaining the National Zoo’s preeminence in the zoo community. However, several problems need attention if positive changes to ensure animal health and welfare are to continue. These problems include immediate needs identified in the interim report as well as the recommendations made in this final report. Most pressing of these recommendations is the establishment of rigorous animal-care staff training as well as a climate of accountability and personal responsibility. Of equal importance are the completion of renovation or construction of animal facilities and the development of a complete and comprehensive strategic plan.

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Animal Care and Management at the National Zoo: Final Report Other recommendations that must be addressed are the establishment of clear standards of professional behavior at all levels; filling the head positions in the clinical nutrition and pathology departments with highly qualified individuals; and following through on efforts currently underway, such as establishing a comprehensive integrated pest management (IPM) effort, developing electronic recordkeeping systems, and completing and documenting diet evaluations. For the zoo to regain its preeminence in the zoo community, the leadership of the Smithsonian Institution and the zoo must ensure that resources and support continue to flow into the zoo so that it can address these major obstacles. COMMITTEE’S TASK The National Academies was explicitly charged to focus narrowly, considering only those matters that related specifically and directly to animal management, husbandry, health, and welfare. Only those aspects of conservation, education, and science that affect animal care and management were within the scope of this review For example, the committee was not asked to review the education programs, the scientific quality of the research carried out at the zoo, or the scope or effectiveness of its conservation programs. Evaluating the adequacy or inadequacy of funding to support the various zoo activities or making recommendations on personnel or leadership changes was not within the committee's charge. It is beyond the scope of the committee’s charge to dictate either specific remedies to address the recommendations of this report or specific time frames for effecting change, as there are many factors that will influence decision-making, such as the skills and workloads of individual staff and the availability of resources (human and capital), about which the committee lacks information. Instead, the committee identifies performance measures that the zoo has implemented to monitor the effectiveness and timeliness of recent changes, and comments on the adequacy of these measures, or notes where additional performance measures are needed. Ultimately, the zoo director and senior management must be held accountable for effectively correcting deficiencies in a timely manner. In this final report, the findings deal primarily, but not exclusively, with issues not addressed in the interim report, such as the strategic plan, human resources, training, and occupational health and safety. This final report discusses whether the institution is responding adequately to concerns raised in the interim report and addresses three additional topics: a scientific evaluation of recent animal deaths, a review of CRC operations to determine whether the problems at the Rock Creek Park facility identified in the interim report were also evident at the CRC, and an assessment of whether practices and physical conditions at the zoo were improving. PROGRESS AT THE NATIONAL ZOO SINCE RELEASE OF INTERIM REPORT Since the release of the interim report, which dealt almost exclusively with the Rock Creek Park facility, the zoo staff and management have expended enormous time and energy to enact positive changes at the zoo as quickly as possible. Some of the changes were in response to findings in the interim report; others, such as reviewing and documenting animal diets in a database, were started before the release of the interim report as a result of the zoo’s own examination of its operations. Over the last 6 months, the veterinary staff have eliminated the backlog of preventive-medicine procedures at the Rock Creek Park facility and staff at both the Rock Creek Park and CRC facilities have reviewed and updated their preventive-medicine protocols and established a monthly performance measure for tracking adherence to their protocols (currently, 100% of scheduled preventive-medicine procedures have been completed). The zoo’s nutrition staff have developed a schedule for implementing a centralized commissary at the Rock Creek Park facility and established performance measures to track progress. Collaboration between the research nutritionist and the clinical nutritionist was initiated quickly, and review of all animal diets and their entry into a database have progressed at a reasonable rate. Diet evaluation and documentation have been completed for mammals, birds, reptiles, and amphibians at the zoo; only the diets of invertebrates in the collection still need to be reviewed and entered into the database. The zoo has made considerable progress in complying with federal statues to ensure animal welfare. The composition of the zoo’s institutional animal care and use committees (IACUCs) has been appropriately adjusted, semiannual inspections were performed in 2004, training for all IACUC members has been scheduled, and the appropriate documentation has been submitted to federal regulatory agencies.

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Animal Care and Management at the National Zoo: Final Report To address shortcomings in recordkeeping long-term, the zoo is contributing to the Web-based zoological information management system (ZIMS) that is being developed by the International Species Information System (ISIS). This system will not be available for several years, so the zoo has taken steps to deal with recordkeeping deficiencies in the interim. The zoo is developing and testing a standardized electronic keeper record system and is developing software to make the MedARKS medical-records system electronically accessible and compatible with current Web-based intranet hardware and software. Both developments were scheduled to be implemented by the end of 2004. In addition, in collaboration with the Smithsonian Institution, the zoo developed and implemented new standards for the filing and retention of records. Finally, the pest-management program at the Rock Creek Park facility has made a number of facility improvements to control the rodent problem at the zoo. Overall, the committee believes that the zoo has taken the committee’s recommendations seriously and is making good-faith efforts to correct deficiencies noted in the interim report. Progress has been more impressive on some fronts than on others, and a number of weaknesses are still apparent, though the committee recognizes that additional improvements will have been made in the months since it last met. In order to build on the positive progress that has been made in the last 6 months, senior management at the zoo must ensure continued progress in the areas of animal care and management, recordkeeping, pest control, strategic planning that were addressed in the interim, as discussed in Chapter 7 of this report. LONG-TERM SUCCESS OF ANIMAL CARE AND MANAGEMENT AT THE NATIONAL ZOO In the following sections, the committee presents its findings and recommendations on issues important for the long-term success of animal care and management at the zoo. The committee assessed the zoo’s strategic plan; its management of communication, knowledge, and human resources; the animal care and management operations at the CRC; as well as a scientific examination of recent animal deaths. Training and Development of Animal-Care Staff For the most part, the current cadre of keepers at the zoo had no prior experience in the care of zoo animals when they began as volunteers or employees of the zoo. Since at least 1992, training for keepers has been informal and has not followed a common protocol. Consequently, verbal descriptions of the goals and content of training initiatives of the zoo are inconsistent and vague and have resulted in husbandry training that is highly variable across the zoo. The zoo needs to develop effective mechanisms for ensuring that people who are directly responsible for the care and well-being of its animal collection are adequately prepared and competent. The zoo has no documentation outlining the content or goals of a training program for animal-care staff. This lack of formal training or well-structured informal training has been noted in every AZA accreditation report since 1992. There is an informal training system where new keepers follow veteran keepers for a period of a few days to 2 weeks, but there are no written requirement for the length of time that a new keeper should spend in training, what information and protocols new keepers should be taught, how to assess the quality of the training, or how well the training was assimilated. In 2003, the zoo determined that all assistant curators in animal programs should receive management training through the AZA Management School; by the end of 2004, three of eight assistant curators will have taken this course. There is no documentation that additional training is offered to improve leadership and management skills of assistant curators at the zoo. This current state of training and professional development at the zoo does not foster the expectation that staff will assume responsibility to stay abreast of innovations and further their education and development in their respective fields. Keepers and assistant curators tend not to participate in continuing education opportunities because, they state, the animal program is understaffed. In fact, over the last 10 years, the keeper staff increased while the number of animals in the collection declined by 50%. Recommendations:

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Animal Care and Management at the National Zoo: Final Report The zoo should develop and implement an animal-care training program for its keeper staff immediately. This action requires establishing written husbandry protocols for each species at the zoo, standardizing the information to be passed to new keepers during training, designing a formal assessment of learned information, and instituting a formal system for documenting compliance with training requirements. The management team directly responsible for overseeing the day-to-day care of the animal collection (assistant curators) must undergo some form of management training. Adherence to Policies and Procedures In an effort to create a climate of accountability and responsibility, zoo management is undertaking the daunting task of updating and revising the Best Practices Manual. The zoo is holding all-supervisor meetings to make certain that supervisors are familiar with zoo policies and protocols. However, the zoo still needs to address how it plans to train all employees uniformly on zoo procedures. Also, it has not been adequately communicated that all supervisors, including senior management, are accountable for management failures that allow repeated lapses or poor performance in any aspect of zoo operations. The zoo is updating and revising its zoo-wide policies with input from each unit, but protocols for husbandry, management, and enrichment have yet to be developed in many cases. The zoo has implemented a series of performance measures that set goals for supervisors in the veterinary and nutrition departments in particular, but performance measures to monitor the Department of Animal Programs and individual units have yet to be developed. Recommendations: The zoo should develop performance measures to monitor the operations of the Department of Animal Programs and individual units as a mechanism for managerial accountability. The zoo must continue to clarify the roles and responsibilities of all staff. Inherent in this task is identifying who is accountable for decision-making and ensuring adherence to policies and procedures. Strategic Planning As described in the interim report, the zoo operated without a strategic plan or its equivalent since at least 1992. Thus, the zoo functioned for many years without a firm sense of direction, which might have contributed to the decline in the animal collection and facilities during the 1990s. In May 2004, the zoo completed its strategic plan as part of a Smithsonian-wide process. The strategic plan is a good articulation of the mission and 10-year vision of the National Zoo and includes a bold proposal to integrate the CRC science programs with the Rock Creek exhibits and programs, thereby creating a unique niche in the larger zoo community that cannot be fulfilled by the Rock Creek Park facility alone. The elements of the zoo’s strategic plan include a mission statement, a description of core values, a 10-year vision statement, 1-year and 5-year goals, and six strategies for achieving the goals. The main 1-year and 5-year goals pertaining to animal management include goals to implement a comprehensive recordkeeping system; to clarify the roles, responsibilities, and decision-making processes related to animal care and management; to establish a collection and exhibit planning process that will guide decisions on acquisitions and animal relocations; and to continue to upgrade and improve the quality of the exhibits. Although the 1-year and 5-year goals described in the strategic plan support the zoo’s long-term vision in a general way, the strategic plan has several major weaknesses. The zoo did not engage in a situational analysis of its internal and external operational environment. That omission undermined efforts to develop a plan that builds on the strengths of the zoo and adequately anticipates the resource needs and obstacles that will arise as the zoo tries to attain its long-term vision over the next 10 years. The strategic plan also lacks a galvanizing operational plan for

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Animal Care and Management at the National Zoo: Final Report action and does not include any details on how the zoo intends to attain the 1-year and 5-year goals. The strategic plan also does not link the zoo’s vision with the animal-acquisition plan, in that it is unclear how the zoo’s vision will be expressed through the types of animals exhibited. Finally, the strategic plan does not take into account how the timeline for renovation and construction of animal exhibits should influence the animal-acquisition plan so that expansion of the animal collection will not tax facilities that are already failing. Recommendations: The zoo should perform a situational analysis and use this analysis to reassess the goals and vision of the strategic plan. A detailed operational plan for attaining the 1-year and 5-year goals of the strategic plan should be developed. Appropriate performance measures should be identified to track the zoo’s progress in attaining the goals of the strategic plan. These measures should be evaluated at least annually to determine whether those goals are being met and whether the strategic or operational plan requires modification. The strategic plan should directly link the plan for revitalizing the physical facilities with the animal acquisition plan to ensure that planned expansion of the zoo’s animal collection can occur without taxing already failing facilities and compromising animal and staff safety. Communication As evidenced in its own strategic-planning process, the zoo recognizes that communication is critical for its own revitalization and for ensuring high-quality animal management and care. Effective communication has been a challenge because the zoo and its individual departments are organized hierarchically. Even within a single department, such as animal programs, units are largely isolated from one another; bottom-up communication is not well established; top-down communication has been inconsistent; and electronic communication has been utilized inconsistently. It is unclear whether written materials, such as policies and procedures, are read and assimilated by the animal-care staff and many employees do not feel that they have a voice within their unit or the organization. Management recognizes that improvements in communication are critical for revitalizing the zoo and ensuring high-quality animal care and management, and is taking steps to remedy some of those long-standing deficiencies. Associate curators now visit their units regularly, interdepartmental meetings are more frequent, and work assists (moving employees to units others than their own to provide advice on particular issues) are more common. All employees had multiple opportunities to provide input to inform strategic planning process. Management holds regular “town hall” meetings at both campuses. There is also increasing use of electronic technology, especially two-way radios, in zoo operations. Recommendations: The zoo should continue efforts to facilitate communication among and within departments and to improve communication between different organizational levels. There are many potential ways to achieve improvement: formalize regular interdepartmental meetings, expand the use of cross-functional assignments and cross-training, and formalize the use of available technological resources for enhancing communications within and across the various units of the zoo. Management at the zoo should be persistent in efforts to facilitate communication up and down the organization as a whole and in the chain of command in each unit. The zoo should develop a plan and process for monitoring adherence to and evaluating the outcome of standards, policies, procedures, special guidelines, and other aspects of communication. Staff training in communications is necessary to ensure that these policies have been assimilated and understood, and that there is accountability for adherence at all levels. The zoo must endeavor to build a sense of community for its employees and create professional relationships between various departments and individuals.

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Animal Care and Management at the National Zoo: Final Report Knowledge Management In the past, the zoo has lacked the ability and commitment to capture, archive, and retain existing institutional knowledge. There is no mechanism for capturing employees’ knowledge so that it is not lost when they transfer between units or leave the organization. The zoo has a long history of deficiencies in continuing education and has relied heavily on an internal-development strategy: open positions are filled from within the zoo rather than by hiring from outside. This practice has limited the amount of new knowledge flowing into the institution. Not all departments in the zoo have used the computer network effectively to store information so that it is properly archived and accessible to others. As a result of those practices and the lack of a formal plan for the management of institutional knowledge, the zoo’s knowledge base has stagnated. The zoo until recently has not been diligent in promoting a learning environment where employees have a shared understanding of what the organization is trying to accomplish, employees are accountable for learning and their own performance, new ideas are valued and encouraged, and policies and practices support the effective use of training. The zoo relies heavily on an internal development strategy, which, coupled with a lack of continuing education opportunities, creates an insular culture and isolates the zoo from outside perspectives and innovations. The zoo has recognized some of these problems and has made major improvements by updating standards, policies, and procedures; advertising open positions more broadly; using work assists; soliciting ideas and information from employees through the strategic-planning process and in efforts to update policy manuals; and holding “all-hands” meetings with the zoo director. Recommendations: The zoo should develop appropriate electronic storage of knowledge and enable employees to locate and access information in a just-in-time fashion. To improve the knowledge base among staff, the zoo should develop recruitment strategies to ensure an appropriate balance of staff recruited from outside and those transferred or promoted from within the organization. The zoo should develop additional strategies for capturing and retaining existing institutional knowledge that is being lost through the departure of experienced staff. The zoo should conduct an assessment of its learning environment to identify barriers to and opportunities for implementing initiatives for advancing the work culture as a learning environment. Human-Resources Planning and Use The zoo does not have its own human-resources plan, and the current strategic plan does not include projections of the staffing levels necessary to support the new strategic vision of the zoo. The centralized Smithsonian Office of Human Resources (OHR) makes most personnel decisions for the zoo, including employee selection and staff reductions. As a result, staffing decisions often lack a strategic focus. Staffing levels in most units of the zoo appear to be appropriate, but it is unclear how the specific needs of different units are weighed in determining how human resources should be allocated. Staff members have often been assigned to units where they had no taxonomic expertise. In addition, the Smithsonian is subject to the rules of federal employment processes, which can make decision-making cumbersome and protracted. Improvements are evident. The zoo has been working with the Smithsonian OHR to streamline the hiring process by developing more detailed job announcements to reduce the number of applications from unqualified people that have to be processed. The electronic processing of applications and other human-resources administrative actions are under development.

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Animal Care and Management at the National Zoo: Final Report Recommendations: A more efficient hiring process in the zoo and the Smithsonian Institution would increase the likelihood of successfully recruiting top candidates for open positions at the zoo. The zoo should focus attention on developing a human-resources plan based on an analysis of the adequacy of its current staffing levels and projections of staffing necessary to achieve its strategic vision. Review of Individual Animal Deaths at the National Zoo A scientific examination was conducted of recent animal deaths at the CRC and Rock Creek Park facilities. The committee examined medical records, keeper notes, pathology records, curatorial records, and internal memorandums and reports that were provided by the zoo. The committee reviewed 48 individual cases. This review included cases involving megavertebrates1 and other species that were publicized through the media or written comments to the committee (23 cases from Rock Creek Park and 4 cases from the CRC), as well as a random sampling of megavertebrate deaths that occurred from 1999 to 2003 (10 cases from Rock Creek Park and 11 from the CRC). In total, the committee evaluated 74% of all megavertebrate deaths that occurred at the National Zoo from 1999 to 2003. The committee concluded that in a majority of cases, the animal received appropriate care throughout its lifetime. In particular, the committee’s evaluation of randomly sampled megavertebrate deaths at the Rock Creek Park facility revealed few questions about the appropriateness of these animals’ care, suggesting that the publicized animal deaths were not indicative of a wider, undiscovered problem with animal care at the Rock Creek Park facility. The committee’s evaluation of these cases did uncover recordkeeping deficiencies in 17 of the 48 cases. These lapses occurred at both the Rock Creek Park and CRC facilities and made it difficult to determine whether husbandry and veterinary procedures occurred but were not documented or whether the procedures were not performed. The committee’s evaluation of randomly sampled megavertebrate deaths at the CRC facility revealed widespread veterinary recordkeeping deficiencies and potential problems with the preventive medicine program on a scale that is similar to the deficiencies in the preventive medicine program at the Rock Creek Park facility, which were detailed in the interim report. Through its review of these cases, the committee identified a major organizational issue that created an environment where these human lapses could occur. The lack of open communication and collaboration among keepers, curators, veterinarians, nutritionists, and senior management was evident in almost every case where inadequate animal care was evident. The committee observed that the individual departments of the zoo seldom worked collaboratively, disrupting the system of checks and balances and allowing inadequate care to occur. When multiple people are actively involved in the care of each animal, it is less likely that a lapse in care will go unnoticed. A team approach to animal care is particularly important at the National Zoo, whose animal collection is generally geriatric and where a lapse in care may have a greater negative impact. Recommendations: The zoo must take immediate steps to clarify the actions, procedures, and observations that must be included in each type of record created by animal-care, veterinary, and nutrition staff. The apparent inadequate care caused by failures on the part of the veterinary, nutrition, and animal-care staff at the Rock Creek Park facility are being addressed by recent changes in policies and new 1   Defined as elephant, hippopotamus, rhinoceros, zebra, bear, giant panda, lion, tiger, cheetah, gorilla, orangutan, camel, giraffe, sea lion, seal, Przewalski’s horse, and oryx.

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Animal Care and Management at the National Zoo: Final Report initiatives by the zoo. The zoo should continue efforts to establish accountability for unprofessional actions that involved any level of staff. This evaluation of recent deaths at the CRC facility reveals widespread veterinary recordkeeping deficiencies, raising concerns about the adequacy of the preventive medicine program at the CRC. Senior management should evaluate whether the veterinary staff was adhering to the preventive medicine program from 1999 until recently and continue its current efforts to establish oversight and accountability for the veterinary staff at the CRC. Evaluation of the Conservation and Research Center The 3,200-acre CRC in Front Royal, Virginia, focuses on the conservation of biodiversity through scientific research, professional training, and education. The CRC Animal and Support Department consists of a Veterinary Division and an Animal Division that cares for a collection of mammals and birds. The animal collection at the CRC is small. As of January 2003, there were 97 mammals of nine, mostly endangered, species and 172 birds of 11 species. In addition to housing animals involved in research, the CRC serves as a holding site, usually temporary, for animals not currently needed for the Rock Creek Park exhibits. The committee reviewed the CRC facility to determine whether there was effective management and care of its animal collection. It used criteria similar to those used in its evaluation of the Rock Creek Park facility, documented in the interim report. Animal Care and Management at CRC To assess the quality of past animal care at the center, the medical records of a random sample of animals representing about 5% of the collection were evaluated. Apparent incidents of inadequate preventive medical care were found for about 18% of the sample. However, the preventive medicine program at the CRC was recently updated, and the committee finds it appropriate for all the taxa maintained at the CRC. Senior management also instituted performance standards for the preventive-medicine programs at both the CRC and Rock Creek Park facilities in May 2004. From May to July 2004, the CRC veterinary staff completed 100% of its scheduled preventive-medicine procedures. There were differences in the immunization protocols at the CRC and Rock Creek Park facilities for the same animal species without any apparent medical justification. Many species of animals are transferred between the two facilities, so it is important that vaccination protocols be developed in coordination to mitigate any infectious disease risk. Recommendations: Senior management should continue to track completion of monthly scheduled preventive-medicine procedures at the CRC facility. The CRC and Rock Creek veterinary departments should collaborate to coordinate their preventive-medicine protocols as animals are transferred between the two facilities. Animal Welfare at CRC The CRC IACUC, like that at Rock Creek Park, is responsible for ensuring the welfare of research and exhibit animals. A review of the CRC IACUC’s activities for the last 5 years indicates that it actively reviewed all submitted animal research protocols. However, it failed to perform its other mandated activities, such as semiannual inspections. In addition, the IACUC’s failure to investigate the death of a Grevy’s zebra in 2000 indicates that it did not clearly understand its mandate to ensure the welfare of all animals in the CRC collection and not only animals used in research. The CRC IACUC has recently taken several steps to reorganize its program to clarify its role and

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Animal Care and Management at the National Zoo: Final Report responsibilities and to improve compliance with federal statues, which includes submitting annual reports, performing semiannual reviews in 2004, and developing plans to provide training to IACUC members. Recommendations: The Smithsonian and the zoo should ensure that the CRC IACUC is fulfilling its stated responsibilities in a timely and complete manner. These responsibilities extend to the entire collection and not only to the animals involved in research. Nutrition Program at CRC At the CRC, the nutritionist, curator, and veterinarian collaborate to formulate diets. Many of the diets have been adapted from dietary formulations recommended by the Species Survival Plan (SSP) management group. In general, the nutrition program at the CRC appears to have been under appropriate control, and the feeding guidelines for all species at the CRC facility are appropriate. There is a standard procedure for altering diets. To avoid previous problems with hay quality, the CRC recently hired contractors to raise and harvest hay. However, problems remain with inadequate storage facilities to maintain hay quality. Recommendations: Adequate storage facilities for hay, on which the entire NZP depends, must be found, and quality control for the hay must be assured. Recordkeeping at the CRC The CRC, like the Rock Creek Park facility, uses a mixture of electronic and paper records. Except for CRC pathology records, the Rock Creek Park and CRC systems are not integrated. CRC keeper records are maintained on paper in the bird unit but are electronic in the mammal unit. Before the adoption of an electronic keeper record system by the mammal unit in 2001, the keeper records were maintained for only 1 year and then returned to the keepers. There are numerous examples of failure to keep adequate medical records in the CRC veterinary hospital. It is unclear why these systematic lapses in documentation of medical observations, procedures, and vaccinations occurred, but it is clear that some veterinarians were simultaneously using hand-written records, some were using an electronic record system, and some were using MedARKS. Recommendations: Immediate steps must be taken to clarify to the CRC veterinary staff the actions, procedures, and observations that must be included in the medical record, and senior management must ensure compliance with these policies. The CRC should transition to new recordkeeping systems in parallel with the Rock Creek Park facility. Pest Control at the CRC The pest-control operation at the CRC facility has not experienced any difficulties. The unified system controlled by the new pest-control officer should minimize any future problems for the facility.

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Animal Care and Management at the National Zoo: Final Report The National Zoo’s Department of Pathology For many decades, the pathology department at the zoo has maintained an extraordinary reputation for excellence. However, a backlog of uncompleted pathology reports from 2000-2003 had accumulated, and annual morbidity and mortality assessments had not been completed. This backlog included approximately 21% of pathology cases from 2003. The department under the leadership of the acting supervisory pathologist has already eliminated the backlog from 2003, has plans to eliminate the remaining backlog by May 2005, and is scheduled to complete the 2003 morbidity and mortality assessment by the end of 2004. Recommendations: Performance measures should be established for the pathology department to monitor operations and ensure that until a permanent supervisory pathologist is hired, the department has adequate staff to meet the pathology needs of the zoo and continue consulting with the larger zoo community. Occupational Health and Safety Programs The zoo’s occupational health and safety (OHS) program is operating effectively, although it remains in a reactive mode. The safety officer is positioned appropriately by directly reporting into the director’s office and is well qualified and knowledgeable regarding Smithsonian policies and procedures, OHS standards, and the principles for managing safety and health programs. The OHS program has a zoo-wide chemical-approval procedure, a comprehensive chemical-inventory database, and consistent safety procedures. In addition, escape drills have been held recently, and the OHS program offers safety-training classes. Those procedures and activities have helped the Safety Program move toward proactive, albeit still in many respects reactive, management of health and safety risks. However, there are still concerns regarding occupational health and safety at the zoo, one of which is the state of the Rock Creek Park health clinic. The health clinic is of inadequate size, floods occasionally, has only one exit, does not have the capability of providing complete health monitoring of workers, and is poorly equipped for emergency care. Although the OHS program has written policies in place on good safety practices, there has been a lack of compliance with these policies in some areas of the zoo; for example, primate keepers feeding great apes without ready access to a two-way radio and failing to wear attire that conforms to safety policies. There is also a concern with the zoo’s zoonosis program: testing and immunization requirements are not being determined by personnel trained and experienced in occupational health and infectious disease and as a result are inconsistent across the zoo. Recommendations: The zoo’s Safety Department should continue to shift its emphasis toward a more proactive, anticipatory role rather than reacting to events as they occur. Formal written policies pertaining to good safety practice should be enforced, and senior management should ensure inclusion of OHS training in a comprehensive training program for animal-care staff. Safety department staff trained in occupational health and infectious disease should determine the testing and immunization requirements for zoo employees based on a hazard and exposure assessment developed with input from unit supervisors. The Smithsonian Institution must correct the deficiencies in the health clinic facilities at the Rock Creek Park facility.