To fully benefit from its death review process, the department should implement the resulting recommendations.
The Department's, Risk Management Division reviews hundreds of cases a year and has identifies case-practice, operational, systemic and best practice factors as a result of the ongoing review process. The Division has developed a "Lessons Learned" training series as a means to provide existing staff with actual but de-identified key factors and systemic issues that have impacted many of the reviewed number of cases. These Lessons Learned training series are discussed with Regional Administrators (RAs) during monthly meetings and provided as a 'Training for Trainers' briefing in order to prepare and inform the RAs of the key issues of concern. In turn management provides line staff with training opportunities to further discuss and incorporate the key factors into practice. These Lessons Learned training series are further archived on the Risk Management Division's website on the department's intranet system for easy reference by staff. Additinoally, the Lessons Learned are incorporated into the new DCFS Academy curriculum for new Children's Social Workers (CSWs). As part of the Academy simulated classroom experiences are conducted in a safe place through a simulation lab which provides "real life simulations and scenarios" for new hires to practice and develop new skills to employ in the field.
Implementation Date: Partly implemented. Full implementation expected to be completed by December 2013.
The Department has taken steps to disseminate "lessons learned" and implement recommendations from the critical incident/fatality review process. If a recommendation relates to a change in policy, the Department revises the policy as appropriate. Sometimes, the recommendation requires a practice change and recommends notice to staff or additional training of staff. If the recommendation relates to what appears to be a systemic practice issue, the Department has developed a training/communication plan designed to implement those recommendations as described below.
Beginning in August 2013, the Department started using actual (de-identified) fact scenarios from actual cases where there was a critical incident or fatality. Specifically, these fact scenarios form the basis of simulation training provided to our new Social Workers. In the simulation training, the worker participates in a simulated home call and/or investigation wherein their response is reviewed and critiqued by training staff. The worker receives feedback along with a tape of their "performance."
Additionally, starting in December 2013, the Department will begin disseminating to managers, select de-identified fact scenarios of critical incident/fatality cases. The scenarios will call out practice lapses as identified in and recommended by the review process. Managers will review the scenarios and discuss practice lapses with their Social Workers.
Responsible staff: Maryam Fatemi and Dawna Yokoyoma, Deputy Directors over the Service Bureaus; Patricia Dennis, Division Chief over Policy and Training; Francesca LeRue, Division Chief over Risk Management Division
The department agrees with this recommendation and will continue to improve its death review process by providing quarterly reports to the Board of Supervisors regarding corrective action plans resulting from administrative review roundtable discussions (administrative review). In fact, the department has been providing to the Board of Supervisors the results and actions taken following each administrative review. Previously, the department's Risk Management Division provided the Board deputies with draft versions that were not finalized due to the potential for liability. Currently, Risk Management includes the case, operational, and systemic issues including action plans to enhance policy and practice in the final report sent to County Counsel which is shared with the Board of Supervisors.
The Risk Management Division has consulted with County Counsel on how to share "lessons learned" with line staff while adhering to confidentiality restrictions. As such, deputy directors now receive a copy of the reports sent to the Board of Supervisors and the deputy directors utilize these reports to communicate with the associated line staff on case practice issues and policy violations. The Risk Management Division is currently conducting presentations of the fatality reporting process at each regional offices and will be done by June 2013. Internal Affairs, Critical Incident/Child Fatality, and Child Abuse Child Index (CACI) presentations will follow.
Although the department has taken steps to provide greater access to its child death reviews, its response does not indicate that it has taken specific steps to implement recommendations resulting from those reviews.
The department is working with its legal counsel to determine how it can best implement this recommendation. (See 2013-406, p. 125)
Agency responses received after June 2013 are posted verbatim.