Quality Improvement in 2 nd Party Reviews

1. Quality Improvement in 2nd Party Reviews

2. LEARNING OBJECTIVES

3. LEARNING OBJECTIVES • Define key safety constructs • Present the underlying principles and interrelationships between constructs • Examine the role of the reviewer related to ‘content vs. process’ feedback

4. SECOND PARTY REVIEW - DEFINITION “Second Party Review” means an administrative review of the automated assessment tool and investigative file, performed by a higher level staff person [sic other] than the investigator’s immediate supervisor, necessitated by high risk and safety factors as indicated in the automated assessment tool .” 65C-30.001(124) F.A.C.

5. SECOND PARTY REVIEW - PURPOSE “The purpose of the review is to examine the decisions of the supervisor and either validate the supervisor’s recommended course of action or determine the need for alternative or additional action by either the supervisor or CPI.” 65C-30.001(124) F.A.C.

6. Before we expand on the role of a second party reviewer let’s make sure we have a shared understanding of some common safety terms.

7. Child Protection - Key Terms While safety and risk are frequently used interchangeably – they do not mean the same thing.

8. Safety vs. RiskA Critical Distinction In many contexts the concept of risk tends to be generalized to any condition of harm or timeframe, present or future. A safety threat is a narrower construction of risk with the immediacy of the action limited to the present or near future. . .

9. Risk vs. Safety Threat Safety: Defined by the extent to which a caregiver’s actions or inactions present imminent threats of serious harm. Risk: The likelihood of future maltreatment recurrence.

10. SAFETY THREAT Acts or conditions that have the capacity to seriously harm any child.

11. IMMEDIATE vs. IMMINENT Immediate: A safety threat -not separated in time, acting or happening at once, next in order.

12. IMMEDIATE vs. IMMINENT Imminent: The likelihood of serious harm that is not immediate but that may occur in the near future; impending.

13. IMMEDIATE SAFETY THREAT An investigator arrives at the home to find a three-year old toddler riding a tricycle in the middle the street with no adult present.

14. IMMINENT SAFETY THREAT An investigator’s knock on the door is answered by a five-year old home alone.

15. EMERGING DANGER Emerging Danger: An escalation in the duration, intensity or severity of an active safety threat, or “negative” change in either protective capacities or child vulnerability safety factors.

16. An Enhanced Model of PracticeSafety vs. Risk SIGNS OF PRESENT DANGER PROTECTIVE CAPACITIES CHILD VULNERABILITIES The Initial In Home Safety Assessment was designed to differentiate between safety and risk by using three new constructs to “quantify” safety threats. Integrating information from all three constructs should lead to more informed and structured determinations regarding necessary safety actions.

17. SAFETY INVOLVES AN INTERACTION OF THREE CONSTRUCTS

18. PRESENT DANGER Observable indicators of danger which are either ameliorated or exacerbated by parental Protective Capacities and/or a Child’s Vulnerability Child Vulnerability Protective Capacities

19. Present Danger Family or individual strengths/resources or lack thereof that reduce or increase threats of serious harm from arising or, enable or impairs a caregiver’s ability to meet a child’s basic needs Child Vulnerability PROTECTIVE CAPACITIES

20. Present Danger The degree to which a child cannot avoid, negate or modify the impact of safety threats or missing insufficient protective capacities CHILD VULNERABILITY Protective Capacities

21. WHICH PRESENTS THE GREATER SAFETY THREAT? • Sign of Protective Child Present Capacities Vulnerability Danger • 16 year-old ? 11month old mother • 72 year-old ? 11month old grandmother

22. WHICH PRESENTS THE GREATER SAFETY THREAT? • Sign of Protective Child Present Capacities Vulnerability Danger • 16 year-old Estranged from Family 11month old mother • 72 year-old Has Extended Family 11month old grandmother

23. WHICH PRESENTS THE GREATER SAFETY THREAT? • Sign of Protective Child Present Capacities Vulnerability Danger • 16 year-old Has Extended Family 2 yr.-old mother potty trained • 16 year-old Has Extended Family 2 yr.-old mother not potty trained

24. SIGNS OF PRESENT DANGER SAFETY PROTECTIVE CAPACITIES CHILD VULNERABILITY

25. CONTENT CONSIDERATIONS IN SECOND PARTY REVIEWS Conduct state and federal records checks . . . Determine composition of family . . . Determine nature and extent of injuries . . .

26. CONTENT Conduct state and federal records checks . . . Determine composition of family . . . Determine indications of abuse and nature and extent of injuries . . . Are the core elements of the investigation documented clearly enough for you to make a determination regarding safety?

27. Examples of Content Guidance “Obtain collaterals . “ “Continue as discussed.” “Obtain 911 call-outs and LE reports.” “Ensure photos in file to reflect no injuries.” “UA the prospective father.” “Obtain medical records regarding injury and make CPT referral since child is under 5.”

28. Content Considerations Signs of Present Danger

33. IMPLICATIONS FOR CHILD SAFETY Immediacy of the Safety Threat Immediate, Imminent, Emerging . . . Second Party Reviewers should note whether or not the investigator has clearly defined the immediacy of the safety threat for every observable ‘Sign of Present Danger’ .

34. IMPLICATIONS FOR CHILD SAFETY Chronicity of the Safety Threat 6 Chronicity Elements to Document . . . There is a pattern of continuing, escalating and/or increasing frequency of incidents . . . For every documented maltreatment Second Party Reviewers should note whether or not the investigator has clearly defined the chronicity or escalation history of the safety threat (Safety Factor #11).

35. IMPLICATIONS FOR CHILD SAFETY Chronicity of the Safety Threat Initial Maltreatment Maltreatment Recurrence Multiple Recurrence Cross-type Recurrence Timeframe Severity For every documented maltreatment Second Party Reviewers should note whether or not the investigator has clearly defined the chronicity or escalation history of the safety threat (Safety Factor #11).

37. THE SECOND SAFETY CONSTRUCT CHILD VULNERABILITY: The degree to which a child cannot avoid, negate or modify the impact of safety threats or missing or insufficient protective capacities.

38. Content Considerations Child Vulnerability

39. SIGNS OF PRESENT DANGER SAFETY Displays patience and understanding of son’s condition. PROTECTIVE CAPACITIES CHILD VULNERABILITY Developmentally delayed 6 year-old.

40. SIGNS OF PRESENT DANGER SAFETY Does not recognize developmental delay; verbally abusive PROTECTIVE CAPACITIES CHILD VULNERABILITY Developmentally delayed 6 year-old.

41. Content Considerations Child Vulnerability • Other signs . . . • Targeting or scapegoating • Inconsolable crying • Enuresis or encopresis • Inhibited temperament • Adaptive sexuality following sexual abuse • Physical/emotional traits of one parent that other parent despises • Being born of a different father than current male caretaker

42. IMPLICATIONS FOR CHILD SAFETY Signs of Child Vulnerability AGE OF VICTIM The younger the child the more likely they are to be involved in a report involving a child death. Specifically, children 2 years-old and younger were responsible for 73% of the verified child deaths in 2006.

43. Content Considerations – SF #17 Child Death Data 2006 2 Years Old and Under 73% UNDER ONE 34 % ONE YEAR OLD 22 % TWO YEARS OLD 17 % THREE YEARS OLD 7 % FOUR YEARS OLD 6 % FIVE YEARS OLD 3 % SIX OR OLDER 11 %

44. IMPLICATIONS FOR CHILD SAFETY Signs of Child Vulnerability ANY CRYING INCONSOLABLE CRYING New research has indicated that some individuals are upset by any amount of crying by an infant. These “sensitive” individuals react strongly to even the initial cries or whimpering from a child, not just what was formerly described as inconsolable crying. Make sure your investigators are aware of this possible dynamic between child and caregiver.

45. The Third Safety Construct Protective Capacity Individual or family history, strengths and resources (or lack thereof) that either reduce, control and/or prevent threats of serious harm from arising, or have an unsafe impact on a child.

46. Content Considerations Protective Capacities

47. Content Considerations Protective Capacities

48. Protective capacities are strengths or resources specifically relevant to child safety: 30. Questions for determining adequacy of family supports . . . “Who else is interested in keeping your child/family safe?” For “Don’t know,” responses: “Who attended your child’s last birthday party?” “Who would you call if you had to have a babysitter in the middle of the night?” “Who last drove you to the grocery store/health clinic, etc.?”

49. PROCESS Is the rationale for the decision(s) clearly defined and was the appropriate decision reached?

50. PROCESS CONSIDERATIONS IN SECOND PARTY REVIEWS Determine person responsible for abuse . . . Determine protective, treatment, and services to ensure safety . . . Determine risk through utilization of standardized risk assessment . . . “DO THE NEXT RIGHT THING FOR THE CHILD . . .”