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Lessons From the Cockpit:. Rethinking Multidisciplinary Investigative Teams. Lessons From the Cockpit. Donna M. Pence, BS Special Agent - Tennessee Bureau of Investigation-Retired Senior Trainer, Academy of Professional Excellence San Diego State University dpence@projects.sdsu.edu
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Lessons From the Cockpit: Rethinking Multidisciplinary Investigative Teams
Lessons From the Cockpit • Donna M. Pence, BS • Special Agent - Tennessee Bureau of Investigation-Retired • Senior Trainer, Academy of Professional Excellence • San Diego State University • dpence@projects.sdsu.edu • Charles Wilson, MSSW • Senior Director • The Sam and Rose Stein Endowed Chair in Child Protection • Chadwick Center for Children and Families, • Rady Children’s Hospital San Diego, California • cwilson@rchsd.org Wilson & Pence, 2011
Spring of 1984 “You’re supposed to be helping............ but your making it worse!” Wilson & Pence, 2011
Models of Child Abuse “Teams” • Joint Investigation Models • Standing Coordinating/Case Review Teams • Teams in Defined Areas/Jurisdictions • Co-Located Teams Wilson & Pence, 2011
Why Teams? • Increases the likelihood of appropriate outcomes • Reduces the repetition of interviews* & other investigative tasks • Support system for individual team personnel • Safety issues • Cases less likely to “fall through the cracks” • Better case decisions • Reduces the likelihood of single individual making key decisions Wilson & Pence, 2011
What Questions Need to Be Answered by the Investigation? • WAS THIS CHILD (or others) ABUSED? • CAN WE DETERMINE BY WHOM? • WHAT MUST WE DO TO PROTECT THIS CHILD OR OTHERS? • CAN WE HOLD THE ABUSER ACCOUNTABLE? • DO WE HAVE THE EVIDENCE TO SUPPORT OUR CONCLUSIONS? Wilson & Pence, 2011
What’s a CAC? • First – It’s a Team • Law Enforcement • Child Protection • Prosecutor/ Legal • Medical • Mental Health • Victim Advocacy Wilson & Pence, 2011
Go Back to the BasicsWHAT MAKES A TEAM A REAL TEAM? Wilson & Pence, 2011
Definition of a Team A group of people who are necessary to accomplish a task that requires the continuous integration of the expertise (along with resources and authority) distributed among them. Wilson & Pence, 2011
Successful Teams Have: • TEAM INDENTITY • INTERDEPENDENCE • TRUST • TASK SKILLS Wilson & Pence, 2011
To Succeed Teams Must Have: • Task Expertise • Team members must possess the ability to integrate their different skills, expertise, and roles • Team members must be willing to work together in a more complex system Wilson & Pence, 2011
Goal: Safety and Protection of Children Collaboration Collaboration The arrows represent information or practice when working collaboratively Wilson & Pence, 2011
Essential Components of CAC Team • All 6 Disciplines Represented • Law Enforcement • Child Protection • Prosecutor/ County Counsel • Medical • Mental health • Victim Advocacy • All Involved in the Investigation • Routinely Share Information • Written Agreement-Protocol Wilson & Pence, 2011
Investigative Protocol • Establishes the basic mode of operation of the Team • Gives all Team members a common frame of reference • Can be easily modified on a case by case basis Wilson & Pence, 2011
Issues With Protocols • Are they a fiction? • Are they selectively followed? • Are they clear, specific, and comprehensive? • Are we trained to follow the protocol? • How are new Team members introduced to the protocol? Wilson & Pence, 2011
Culture “Culture is what everybody knows, that everybody else knows.” Veronica Abney “What you do and ‘know’ without ever thinking about why you do it or where you learned it.” Donna Pence Wilson & Pence, 2011
Culture is Defined By: • Shared experiences (often historical) • Traditions • Values and Belief System • The Meaning of Behavior • Language • Dress • Food • Common Enemies Wilson & Pence, 2011
Teaming in Large Regions is Hard • Sheer size of populations • Numbers of jurisdictions • Sheer size of area • Sheer numbers of CPS, law enforcement, prosecutors and others Wilson & Pence, 2011
Team vs. Crew • Team-known members-trust, interdependent, strong identity, protocol can be flexible based on individuals skills and talents. Trust people • Crew-Ad hoc, members may rarely work together-role definition much more important, pre-investigation meeting/communication critical, need to create a team culture that transcends individuals. Trust protocol/systems Wilson & Pence, 2011
Crew Embedded in Team Environment • Guided By Law, Policy, and Protocol • Community Culture • Management Team • Crew--the Case Working Team--Guided by Policy, Culture, and Checklist Wilson & Pence, 2011
Three Tools To Guide the Team • The Protocol- a document outlining the mission of the child protection team process, outline of basic goals, roles, agreements, and commitments. This document would be signed by all participating stakeholders. • Orientation Guide- a guide for all new child abuse detectives, CPS, County Counsel, DA, and hospital staff. • New: Checklist Binder(s) Building on the model of flight checklist binders that guide crews from normal to non-normal operational events in simple short focusing on key points of team contact, processes prone to error or conflict, or points were error has dire. Binder can have additional resources needed in the field such a key phone numbers, code numbers, and timelines. Wilson & Pence, 2011
Lessons from the CockpitCheck List Design Wilson & Pence, 2011
Lessons Learned from Flight Crew Checklists They fall into two broad categories: • Normal Operations • Non-Normal Operations The Checklist Manifesto How To Get Things Right by Atul Gawande. Wilson & Pence, 2011
Checklists Are Short • 5-9 items • Don’t cover every step-They focus on the difficult, important but easily overlooked, or those with dire consequences Wilson & Pence, 2011
Checklists Fall Into Two Categories • Do-Confirm • Read Do Wilson & Pence, 2011
Each Checklist Formatted in Similar Manner-San Diego Format • Topic: • Investigative Phase: • Type of Abuse or Neglect: • Who is involved? • Importance: • Checklist (5-9 items) Wilson & Pence, 2011
San Diego CPT Checklists • Convening the Team • Photo documentation of injuries or location where the injuries occurred • Severe Physical Abuse with multiple caretakers and unclear perpetrator • Interview with Medical Provider: Implications of Medical Findings • What information to seek in Minimal Facts Field Interview • How to structure the Minimal Facts Field Interview • Need for Immediate Trauma Mental Health Assessment and Support • Trauma Informed Removal • Placing a Hospital Hold • Arranging a sexual abuse exam at Rady Children’s • Arranging for medical evaluation of physical abuse injuries • Collaborating and Assessing Allegations of Child Sexual Macro Case-Multiple victim/Multiple Perpetrator Allegations Wilson & Pence, 2011
What are the team tasks that lend themselves to 5-9 item checklists in Tennessee? Wilson & Pence, 2011
The Checklist Manifestoby Atual Gawande Metropolitan Books- 2010 Wilson & Pence, 2011
Link from the Field to the Team Meeting • Standing Agency Representatives • Shared Leadership • Technology Supported Wilson & Pence, 2011
Team Meetings • WHAT GOOD DOES IT DO TO TALK? • HOW WILL THE TEAM BE NOTIFIED OF MEETINGS? • WILL THE MEETING ALWAYS BE AT THE SAME LOCATION? • HOW OFTEN DO WE MEET? • WHO CONVENES THE MEETING? Wilson & Pence, 2011
Case Decision Making: • Was this child abused? • Can we determine by whom? • What must we do to protect this child or others? • Can we hold the abused accountable? • Do we have the evidence to support our conclusion? • What’s wrong with our evidence?* Wilson & Pence, 2011
Children need our skills, knowledge, cooperation and caring to help them grow. Let’s do it right! Wilson & Pence, 2011
26th Annual San Diego International Conference on Child & Family Maltreatment www.chadwickcenter.org • Conference: January 23-26, 2012 • Pre & Post-conference Institutes: 21-23 & 27 • Town and Country Resort and Convention Center, San Diego, CA Wilson & Pence, 2011