5 Health Care Response to Domestic Violence Quality Assess

Health Care Response to Domestic Violence

Quality Assessment/Program Improvement Tool

The following quality assessment tool is intended to provide clinical sites serving communities with some guiding questions to assess quality of care related to promotion of healthy relationships and intervention related to domestic violence (DV) within their programs. The information is to be used as a benchmark for each program to engage in quality improvement efforts. Complete the tool as honestly and completely as you can—there are no right or wrong answers, and your program will not be penalized for identifying areas for improvement. For questions that you respond yes to, please attach the corresponding form, policy, tool, etc.

For the purposes of providing technical assistance, we are asking that programs/clinics share their responses with their leadership team and the faculty, in addition to the technical assistance provider. Responses will also be shared with the evaluation team. The names of each program will be kept confidential, and findings will only be shared in aggregate (meaning all the programs in general, not identifying specific programs). We will ask your program to complete the tool again in about 6 months.

We hope that this tool will help provide guidance on how to enhance your health program to respond to domestic violence.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0212. Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.

Completed by (title only):
Program/Clinic Name:
Date:
Protocols
	Yes (if so, please attach)	No	N/A	Don't Know
Does your clinic have a written protocol for assessment* and response to Domestic Violence? *Throughout this document, we refer to assessment—rather than screening—for domestic violence. Screening refers to stand alone questions or a self-administered checklist, while assessment includes conversation with the provider that includes anticipatory guidance on healthy relationships, direct questions about DV, and harm reduction strategies and a warm referral to DV services if abuse is disclosed.
Are there sample wording, scripts, prompts, questions, or information on medical/health history/risk assessment forms or EHR for staff to:
Explain to patients why they are being screened for DV?
Inform patients about confidentiality and any mandated reporting requirements?
Ask patients about DV (with sample questions)?
Educate patients about impact of DV?
Discuss ways to stay safe in an unhealthy or abusive relationship?
Do your protocols instruct providers to assess for domestic violence (DV) during:
	Yes	No	N/A	Don't Know
A visit addressing alcohol or other drug use
A visit addressing depression or suicidality
Any primary care visit
Any reproductive or sexual health visit
A wellness visit/Annual exam/Preventive Care

Does your clinic:
	Yes	No	N/A	Don't Know
Provide patients with a written explanation of confidentiality and limits of confidentiality when they check-in?
Have a place to speak with clients privately?
Have a privacy screen on the computer to protect the contents of the electronic health record from being viewed by others?
Have a policy to ensure that providers ask about DV when the patient is alone?
Assessment Methods
How are patients assessed for DV?
	Yes	No	N/A	Don't Know
Patients answer questions on a medical/health history form
Staff review the medical/ health history form and ask follow-up questions
Staff ask the patients questions
Staff to offer a palm-size safety card with information about how violence can impact health
Assessment occurs in a private place
Which staff are primarily responsible for assessing patients for DV? (please pick one) Counselor Medical Assistant NP/RN MD Other (Please explain) ___________________________
How often are patients asked about domestic violence? With each new sexual partner At least every six months At least once a year No established time interval

Documentation of Assessment and Response

On the medical/health history/assessment form(s) are following steps documented?

Yes

No

N/A

Don't Know

Harm reduction strategies were shared

Referral to a domestic violence agency or advocate provided

Intervention Strategies

Does your staff:

Yes

No

N/A

Don't Know

Have sample wording or scripts about what to say and do when a patient discloses DV?

Have sample or scripted tools and instructions on how to do safety planning with patients who disclose current DV?

Have instructions on how to file a mandated report when needed?

Know an advocate or counselor who can provide on-site follow-up with a patient who discloses DV?

Have a safe place where the patient can use a phone at your clinic to call a national hotline or to talk to a local violence advocate?

Do your staff have resource lists that:

Yes

No

N/A

Don't Know

Identify referrals and resources such as shelters, legal, advocacy, for patients who disclose DV?

Identify referrals and resources for perpetrators of DV?

Include a contact person for each referral agency?

Is there a staff person responsible for updating these lists?

Are these lists updated at least once a year?

Networking and Training

Within the last year, has your staff had contact with representatives from any of the following agencies (contact means--called to refer a patient, called for assistance with a patient, called for information about program)?

Yes

No

N/A

Don't Know

Domestic violence advocates or shelter staff

Child protective services

Batterer's intervention group

Legal advocacy/legal services

Law enforcement

Are there any staff who are especially skilled/comfortable dealing with DV that other staff can turn to for help?

Yes No If Yes, please include staff title/position:

Do your protocols advise staff on what to do if they do not feel comfortable or adequately skilled to help a patient when DV is disclosed? (Example: Can staff ‘opt out’ if they are survivors of or currently dealing with personal trauma?)

Yes No

Do any of your staff participate in a local domestic violence task force or related subcommittee?

Yes No If yes, please identify staff and describe task force/subcommittee:

Is there a buddy system or internal referral for staff to turn to for assistance when they are overwhelmed or uncomfortable addressing violence with a patient?

Yes No If yes, please describe:

Within the last two years, have representatives from any of the following agencies either been contacted to schedule a training or come to your clinic and conducted a training for your staff?

Yes

No

N/A

Don't Know

Domestic violence program

Child protective services

Yes

No

N/A

Don't Know

Law enforcement (e.g., DV unit)

What type of training(s) do new staff receive on domestic violence (DV)?

Does your staff receive booster training on assessment and intervention for DV at least once a year?

Yes No N/A Don’t Know

Self-Care and Support

Does your clinic:

Yes

No

N/A

Don't Know

Have a protocol for what to do if a staff person is experiencing DV?

Have a protocol for what to do if a perpetrator is on-site and displaying threatening behaviors or trying to get information?

Provide individual clinical supervision for staff where they can discuss any concerns/ discomfort relating to screening DV cases?

Provide other types (group supervision, case presentation) of opportunities for staff to discuss any concerns/issues/etc relating to difficult cases?

Have an employee assistance program (EAP) that staff can access for help with current or past victimization?

Data and Evaluation

Does your clinic:

Yes

No

N/A

Don't Know

Record the number of patients assessed for DV?

Record the number of patients who disclose DV?

Annually review all clinic protocols relating to DV (both patient and staff related)?

Yes

No

N/A

Don't Know

Do any of your patient satisfaction surveys include any questions soliciting patient's opinions about assessment and intervention strategies for DV?

Provide regular (at least annual) feedback to providers about their performance regarding DV assessment?

Education and Prevention

Does your clinic:

Yes

No

N/A

Don't Know

Provide information to patients on healthy relationships?

Sponsor any client or community education to talk about healthy relationships or indicators of abuse?

Environment and Resources

Does your clinic have any of the following?

Yes

No

N/A

Don't Know

Brochures or information about DV that patients can take

Brochures, cards, information for patients about how violence exposure affects children

Adolescent focused brochures, cards or information about adolescent relationship abuse

Brochures/cards/posters placed in an easily visible location

Has your clinic adapted any materials to make them more culturally relevant for your patient population? Yes No If yes, please describe:

Who is responsible for stocking and ordering materials including safety cards, pregnancy wheels and posters? Please identify staff by title:

Additional Comments and Observations

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