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Nationwide Programs and Initiatives |
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2005-6 Policies and ProceduresPOLICY STATEMENTParticipation in this project (designed for physicians, nurse practitioners, and physician assistants in Indian Health Service and Tribal programs) is a two-year commitment and requires support from the employing agency. Year 1 consists of an intense one-week didactic/classroom training (funded by the Project) that includes an image capture device/software lab, cultural awareness, and participation in various court case scenarios in an actual court room setting with continuing medical education credits. Needed equipment is purchased by the employing agency with a 50% match by the Project. Participants must attend and successfully complete a one-week hands-on preceptorship with one of the expert faculty at that expert's site. Then as each participant conducts the medical examination for a child abuse victim at their respective site, it is documented as legal forensic evidence via video or digital camera. Images from each case are sent to the Project Director for teaching and consultation via the specialized software. If further evaluation is needed, these images are then forwarded to one of the national experts. An intensive one-week beginning preceptorship is required with one of the national expert faculty at the expert's site which is funded by the participant's employing agency.Year 2 consists of mastering the art of forensic documentation with the image capture device, development and implementation of site-specific policies and procedures for case processing, and the development of relationships locally with law enforcement, FBI, victim advocates, social services, US Attorneys, and the Tribal court systems. The participant must attend a special one-week advanced preceptorship training with one of the project's national expert faculty that focuses on interpretation of cases from a consultant's perspective and how to assist other sites. This is funded by the Project. A site visit will be made by the Project Director and a program evaluation conducted. Cases will be discussed monthly via computer as a group via conference call as a mechanism of peer review and quality control (called Grand Rounds). Continuing medical education credits will be provided for all activities in both years through the Indian Health Service Clinical Support Center in Phoenix, Arizona. Upon successful completion, the participant will be awarded a Certificate of Excellence. Successful participants are encouraged to keep this status current each year by attending at least one major national child abuse conference with a medical focus. The participant will then become the resource in their geographic area with the resources of the project still available to them as needed.
MISSIONTo educate Indian Health Service and Tribal medical providers on policies, procedures, and requirements related to the medical evaluation of child abuse victims, interviewing techniques, written consultations, image documentation, and court testimony.VISIONCreation of an Indian Health Service-wide standard of care for the child abuse victim, the creation of a national IHS database and statistical case tracking mechanism, and the establishment of highly qualified experts who can served as resources to Indian Communities.PROJECT GOALS AND TRAINING OBJECTIVESGoal: To improve the clinical diagnosis of the IHS and Tribal physicians, nurse practitioners, and physician assistants in the management of child maltreatment with special emphasis on sexual and physical abuse.Objectives:
SCOPE OF PRACTICEMedical Providers. The IHS Child Abuse Project will train physicians, nurse practitioners, and physician assistants from IHS and Tribal programs to perform the following services:
Program Experts. The IHS Child Abuse Project Director and the project faculty will provide the following services for the participating medical providers:
REFERRAL POLICYMedical providers trained via this program will medically evaluate children allegedly victimized by or witness to alleged incidents of child maltreatment. Referrals may come from law enforcement, social services, prosecutor, court, or child protection team appropriate to that facility or jurisdiction. Regardless of the referral source, all cases see must be reported to law enforcement. Referrals may also be made by another health care provider to assist in the determination of normal variants and abnormalities in pediatric genital anatomy or in the diagnosis of disease.During Year 1 image documentation of ALL medical examinations performed by participants in the project will be sent via telemedicine software to the Project Director for review, assistance, triage, and teaching. The Project Director will make a determination whether a particular case requires further evaluation by a member of the expert faculty. In these instances, the Project Director will review the cases with the expert faculty member and respond back to the initial medical provider with recommendations. After Year 1 and by the determination of the Project Director, only cases with abnormal, unusual, or undetermined findings will be required to be sent to the Project Director. After successful completion of both years of this training, it will be at the discretion of the individual medical provider which cases are sent to the Project Director for review. Verbal consultation on all cases transmitted to the Project Director will be available by telephone/telemedicine on a 24-hour basis. A written hard copy of that consultation will be sent to the medical examiner within 7 working days. A hard copy of a consultation from an expert faculty member may take 10 working days.
SUPPORT DURING THE JUDICIARY PROCESSThe Project Director and the expert faculty members will support project-trained medical providers by providing technical resources. These examiners are asked to utilize depositions/affidavits and other standard law practices when allowed by the courts to minimize court appearances and travel time/costs of the Project Director and expert faculty. If a court appearance becomes necessary, the particular circumstances of a given case will determine responsibility for associated time and travel costs.
MEDICAL FORENSIC INTERVIEWThe medical provider shall create a sensitive and supportive atmosphere for children to discuss alleged events of child maltreatment, domestic violence, homicide, kidnapping, and assault; designed to minimize discomfort and to gather information as objectively as possible within the child's developmental capabilities. The interview alone with the child victim will be conducted in a safe, controlled, and confidential room and progressing from general open-ended questions to focused questions. The non-offending parent or guardian may be present at the request of the child. The content of this interview will be documented and become a permanent part of the patient record. After the interview, the non-offending parent, guardian, or caregiver may be given a verbal summary of the interview and provided with appropriate resource materials. A general and focused medical history and reason for referral will be obtained prior to examination.
MEDICAL FORENSIC EXAMINATIONRelaxed orientation to the child-friendly examination room, medical equipment, and the procedure should occur and will be dependent upon the child's age, developmental level, emotional status, and medical condition. This evaluation will include a complete physical examination and will utilize special medical assessment tools (such as colposcopy, photography, video, specimen collection, x-ray, other) for collecting and documenting evidence of both normal and abnormal findings. A developmental screen and collection of specimens for diagnosis (as indicated) will also be performed. An informed consent form must be obtained with appropriate signatures before the examination takes place. This form will be a permanent part of the patient record. Referral for a medical examination may include but not limited to disclosure or history of body injury or pain, genital or rectal infection, pregnancy, fear for personal health, disclosure of inappropriate personal contact with another child or adult, or sudden unexplained changed in behavior. The examination will be attempted with the child's consent and cooperation with a nurse or other such qualified assistant present. Also present may be the support person of the child's choice (with the exception of the offending parent/guardian/adult). No examination will be performed under restraints or force, which may necessitate the examination being attempted on another day. If the child is uncooperative and the examination needs to be conducted immediately or if the use of sedation is deemed necessary, the examination will be scheduled and conducted in an appropriate facility. Documentation of the medical examination will be done in a timely manner by the medical provider and will be stored in a locked and secure place and preferably NOT a part of the regular clinic record. Such documentation will include all medical examination and related forms (medical form, psychosocial history, developmental history, chain of evidence, informed consent, typed medical consultation, images of injuries, release of records, lab and x-ray results, other). A copy of the completed written medical consultation will be sent to the referring agency(s) (per policy) after review and signature by the medical examiner within 10 working days per policy.
PEER REVIEWThe IHS Child Abuse Project Director will conduct regular case review (called Grand Rounds and conducted either bi-monthly or tri-monthly) via computer and conference call. Specific cases will be transmitted to all participating medical examiners and will be discussed by the group with recommendations and comments made. A log will be kept of cases reviewed, recommendations made, date, and those who participated. This will be scheduled in advance for a one-hour session, and a list of participants will be submitted to the Indian Health Service Clinical Support Center for continuing medical education credits.
DATA COLLECTIONSpecific data must be collected to evaluate the effectiveness of both the process and the outcome of this project. This will include raw statistical data as well as participant evaluation and comments. Both will be analyzed for the purpose of program improvement, program effectiveness, and for justification for future funding. Specific data to be collected is as follows and will be submitted to the Project Director:
YEAR 2 SITE VISIT BY THE PROJECT DIRECTORAs part of the requirements of Year 2, a site visit will be made by the Project Director and a program evaluation conducted. Patient records will be reviewed, those involved with processing child abuse cases will be interviewed (law enforcement, social services, victim advocates, child protection teams, other) site-specific policies and procedures will be evaluated for completeness and perceived impact on care and case processing, the room where the examination is conducted will be viewed, and the way in which the medical provider conducts the examination will be evaluated. Other activities may be observed as the Project Director deems necessary.
Site Specific Policies and Procedures
SUCCESSFUL COURSE COMPLETIONUpon successful completion of this two-year course, the participant will be awarded a Certificate of Excellence. It is to be kept current each year by attending at least one major national child abuse conference per year that has a special medical track (i.e. San Diego, Huntsville, other). Each successful participant will be encouraged to become the "expert" in their respective geographic area with the resources of the project still available to them as needed. |
