|
Team Member |
Records to Supply for
Review |
Role on Team |
Actual Members’
Prevention Actions in MI |
|
Medical Examiner |
Autopsy reports |
Educate non-medical team
members on disease process, mechanism of death/injury. |
Wrote editorial in paper,
did grand rounds re: dangers of bed-sharing w/infants. |
|
Law Enforcement Officer |
Scene investigation reports/
photos; witness interviews; state uniform crash reports;
criminal background checks |
Give details of incident,
inform non-legal team members about role of law enforcement
in scene process. |
Organized Teen Driver Task
Force re: loopholes in GDL law, gravel roads & parent
involvement in program. |
|
Public Health Representative |
Home visits, immunizations,
WIC, maternal/infant support services, prenatal care, birth
records, smoking cessation |
Share knowledge of child’s/
family’s health histories, services utilized, educate team
re: birth info (gest, wt, etc) |
Wrote grant applications,
recruited staff and team members to establish new FIMR
program in county. |
|
Social Services
Representative |
Child Protective Services
histories on caregivers, participation in parent ed, other
support services (homemaking, job skills, etc.) |
Share knowledge of family
social history (divorce, DV, subs. abuse), inform team
members about agency’s definition of abuse / neglect. |
Spearheaded initiative to
supply low-income families with new cribs for infants;
supplied all police officers with 24-hr grief resources. |
|
Prosecuting Attorney |
Court proceedings related to
case, prior adjudications involving family
members/caregivers. |
Educate team members on what
are and are not prosecutable offenses and why; give advice
to law enforcement re: scene investigation/documentations. |
Launched water safety
campaign - increased lake patrols and posted signs at each
lake, obtained funding for swimming lessons and educational
materials. |
|
Pediatrician |
Any health records on child |
Educate team members re:
disease processes in children, share any history w/child. |
Composed letter to high
school seniors and their parents to be distributed in area
schools, encouraging safe driving behavior during prom and
graduation time. |
|
Emergency Medical Services |
EMS run reports from fatal
incident, any prior incidents at that address |
Share facts about incident,
details of scene, impressions of situation in general. |
Asked social workers to help
get smoke detectors in homes that lacked them. |
|
Hospitals |
ER records, surgeries,
in-patient care, OB/GYN info |
Share health records, inform
team about hosp protocols. |
Added safe sleep info to
“Welcome Baby” gift bags. |
|
Community Mental Health |
Marklar |
Educate team about psych
meds, individual and group services available. |
Partnered w/local council to
develop community crisis response to death of a child. |
|
Probate or Family Court |
Delinquency histories,
probation records |
Inform team about court
proceedings, options available for youth in trouble. |
Suggested change to youth
probation protocol when suicide risk is present. |
|
School Representative |
Marklar |
Educate team on school
policy & practices, curricula. |
Tailored ISD annual staff
workshops to address certain CDR findings. |
|
Human Service Collaborative
Rep |
History of board’s
activities related to cause of death/injury |
Advise team on what is being
or could be done on an issue. |
Started a new SAFE KIDS
chapter in the county. |
|
Category of Concern |
Specific Example |
Possible Solution |
|
Leadership |
Team chair
was appointed by supervisor, does not truly buy into CDR
process. |
Send team
chair to state or national CDR training; provide TA & support. |
|
Population |
Urban team
overwhelmed by caseload; rural team experiences attrition from
lack of cases, need for review meetings. |
Urban team
focuses on one cause of death per meeting; rural team begins
reviewing serious injury, prevention. |
|
Information |
Team has
consistent problem with key members missing meetings. |
Have
members designate alternates; coord gets key reports before
meeting. |
|
Administration |
Team
coordinator feels overwhelmed by administrative tasks of running
team. |
Other
members take turns completing various administrative tasks of
team. |
|
Trust |
Agency
members without history of working together do not trust each
other. |
Choose
simple initiative that impacts both to collaborate on, building
trust. |
|
Protocols |
New team
struggles in deciding parameters of team’s activities. |
Team uses
written team protocols as guide, adapting to community’s needs.
|
|
Coordination |
Team feels
disconnected from state level team due to lack of
inter-communication. |
Local
coords. compile findings, send to state team, ask for periodic
feedback. |
|
Reporting |
Team
conducts thorough reviews, but fails to complete/submit case
reports. |
Appoint
agency data analyst to team; sole task is case report
completion. |
|
Efficiency |
Meetings
begin to lack overall focus, effectiveness, efficiency of time. |
Reiterate
goals of process before each meeting; send members to training. |
|
Monitoring |
Team unsure
of how quality of their reviews compares to other teams in the state. |
Through
coord. meetings, make contact with other teams, attend their
reviews. |
|
Mindset |
Team seems
unable to get past tragic events to see bigger picture of
prevention. |
Obtain/share examples of other teams’ successes with prevention
initiatives. |
Factor
|
Specific Example
|
Why This Contributes to Success
|
|
State Support |
State
agencies and government support the concept of the CDR process. |
Although a
bottom-up process, agreement to participate is often top-down. |
|
Legislation |
Enabling &
protecting legislation relating to CDR is passed at the state
level. |
Gives legal
basis for sharing sensitive information; legitimizes process for
some. |
|
Funding TA and Support |
Funds to
cover community consultants are appropriated by participating
agency(ies). |
Expertise
of CDR consultants facilitates formation and sustainability of
teams. |
|
Housing of Program |
CDR staff
are housed in a neutral location, with committed housing
organization. |
Non-threatening to other disciplines involved; lessens turf
issues. |
|
Pre-Organizational Seminar(s) |
A state
with few or no local teams holds regional seminars for
human service reps. |
Introduces
the idea of the CDR process to multidisciplinary audience at one
time. |
|
Organizational Meeting |
Team
convenes first meeting as organizational only; no reviews are
done. |
Provides
opportunity to get acquainted, set parameters before attempting
reviews. |
|
Interagency Agreement |
Agency
directors sign joint agreement to participate in the CDR
process. |
Solidifies
multi-agency commitment and idea of shared ownership in the
process. |
|
Confidentiality Statements |
All members
sign annual confidentiality statements before sharing
information. |
Further
assures members/agencies still wary of liability associated with
CDR. |
|
Training |
Statewide
training provided to new local and state level team members
annually. |
Informs
members about types of death; builds skills for conducting
reviews. |
|
Retro/Practice Reviews |
Team
chooses a number of deaths from recent past as first batch of
reviews. |
Serves as
review practice; raises comfort level of members with the
process. |
|
Buy-In of Core Members |
Agency reps
required by law to be present are committed to CDR; attend all
meetings. |
Sets tone
for other members to follow; raises perceived importance of
process. |
|
Ad Hoc Membership |
Team
coordinator invites individuals who were involved in cases to
those meetings. |
Gives
members clearer pictures of events; facilitates prevention
discussions. |
|
Access to Records
|
Adequate
records on each death are made available to the team for review. |
Increases
team’s ability to understand the circumstances of and report on
the death. |
|
User-Friendly Reporting System |
Reporting
system is easy to use, includes all important info, provides
data feedback. |
Encourages
teams to submit reports, allows them to generate summary data.
|
|
Positive Focus |
Review
focus remains on prospective actions as opposed to
finger-pointing. |
Reassures
members that is a public health process and not a witch hunt. |
|
Deaths Reviewed |
Broad base
of deaths reviewed is inclusive of all preventable deaths, birth
to age 18. |
Improves
team’s ability to identify trends, enhances prevention/policy
development. |
|
Dissemination of Findings |
Findings/recommendations are reported to professionals,
legislators, the public, etc. |
Maximizes
impact of the review process; reinforces members’ commitment. |
