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 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 2Wilson & Pence, 2011

Spring of 1984 “You’re supposed to be helping but your making it worse!” 3Wilson & Pence, 2011

Models of Child Abuse “Teams” Joint Investigation Models Standing Coordinating/Case Review Teams Teams in Defined Areas/Jurisdictions Co-Located Teams 4Wilson & 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, 20115

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? 6Wilson & Pence, 2011

What’s a CAC? First – It’s a Team Law Enforcement Child Protection Prosecutor/ Legal Medical Mental Health Victim Advocacy 7Wilson & Pence, 2011

Go Back to the Basics WHAT MAKES A TEAM A REAL TEAM? 8Wilson & Pence, 2011

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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. 10Wilson & Pence, 2011

Successful Teams Have: TEAM INDENTITY INTERDEPENDENCE TRUST TASK SKILLS 11Wilson & 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 12Wilson & Pence, 2011

13 LAW ENFORCEMENT Guided by the Penal Code Beyond a Reasonable Doubt Gather Physical/Verbal Evidence Power to Arrest Doesn’t have to tell the truth Who, What and How emphasis Is it a crime? JOINT INTEREST Investigation Skills Gathering Facts and Evidence Insure Immediate Safety Determine Removal Determine ”Who, What, When, Where How and Why” It Happened Determine What, if Anything Has Occurred Look for information/evidence that refutes as well as supports allegations Explore alternative hypotheses Drugs CHILD PROTECTION Guided by the Civil Code Preponderance and Clear and Convincing Evidence Gathers verbal evidence Power to Remove Children Is there a failure to protect? Who, How and Why emphasis Family Cooperation Collaboration Goal: Safety and Protection of Children The arrows represent information or practice when working collaboratively

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 14Wilson & Pence, 2011

15 Child Maltreatment Investigation Components Cross Report & Coordinate w/ Other Investigative Agency Reviewing & Gathering Background Information Child Interviewing Adult Interviewing Evidence Identification & Collection: Medical, Physical, Verbal Critical Thinking- Evaluation of Information & Evidence Consultation & Decision- Making Observations & Documentation

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,

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? 17Wilson & 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 18Wilson & Pence, 2011

Culture is Defined By: Shared experiences (often historical) Traditions Values and Belief System The Meaning of Behavior Language Dress Food Common Enemies 19Wilson & 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,

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 21Wilson & Pence, 2011

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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 25Wilson & 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. 26Wilson & Pence, 2011

Lessons from the Cockpit Check List Design Wilson & Pence,

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. 28Wilson & 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 29Wilson & Pence, 2011

Do-Confirm Read Do 30Wilson & Pence, 2011 Checklists Fall Into Two Categories

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) 31Wilson & Pence, 2011

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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,

What are the team tasks that lend themselves to 5-9 item checklists in Tennessee? 34Wilson & Pence, 2011

The Checklist Manifesto by Atual Gawande Metropolitan Books Wilson & Pence,

Link from the Field to the Team Meeting Standing Agency Representatives Shared Leadership Technology Supported 36Wilson & 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? 37Wilson & 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,

Complexity of Change for a CAC Environment 39Wilson & Pence, 2011

40 Children need our skills, knowledge, cooperation and caring to help them grow. Let’s do it right!

26 th Annual San Diego International Conference on Child & Family Maltreatment Conference: January 23-26, 2012 Pre & Post-conference Institutes: & 27 Town and Country Resort and Convention Center, San Diego, CA 41Wilson & Pence, 2011