Program _______________________________________________ Date _____________
To permit formal evaluation of hospital-based domestic violence programs, the Agency for Healthcare Research and Quality (AHRQ) developed a consensus-driven quality assessment tool. Select for background information about the tool, including development and testing, suggested uses, instructions and interpretations, and scoring.
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Category 1. Hospital Policies and Procedures
Category 2. Hospital Physical Environment
Category 3. Hospital Cultural Environment
Category 4. Training of Providers
Category 5. Screening and Safety Assessment
Category 6. Documentation
Category 7. Intervention Services
Category 8. Evaluation Activities
Category 9. Collaboration
For line-by-line instructions and interpretations, select the relevant category number or text link.
| Category No. | Question | No | Yes |
|---|---|---|---|
| 1.1 | Are there official, written hospital policies regarding the
assessment and treatment of victims of domestic violence? If yes, do these policies: |
__No (0) | __Yes (1) |
| a) define domestic violence? | __No (0) | __Yes (2) | |
| b) mandate training on domestic violence for any staff? | __No (0) | __Yes (2) | |
| c) advocate universal screening for women anywhere in the hospital? | __No (0) | __Yes (2) | |
| d) define who is responsible for screening? | __No (0) | __Yes (2) | |
| e) address documentation? | __No (0) | __Yes (2) | |
| f) address referral of victims? | __No (0) | __Yes (2) | |
| g) address legal reporting requirements? | __No (0) | __Yes (2) | |
| 1.2 | Is there evidence of a hospital-based domestic violence task force? If yes, does the task force: |
__No (0) | __Yes (3) |
| a) meet at least every month? | __No (0) | __Yes (2) | |
| b) include representatives from more than two departments? | __No (0) | __Yes (2) | |
| c) include representatives from the security department? | __No (0) | __Yes (2) | |
| d) include physicians from the medical staff? | __No (0) | __Yes (2) | |
| e) include representatives from a domestic violence advocacy organization? | __No (0) | __Yes (2) | |
| f) include representatives from hospital administration? | __No (0) | __Yes (2) | |
| 1.3 | Does the hospital provide direct financial support for the domestic violence
program? If yes, how much annual funding? (Choose one): |
__No (0) | __Yes (0) |
| a) < $5000/year | __Yes (6) | ||
| b) $5000-$10,000/year | or | __Yes (12) | |
| c) > $10,000/year | or | __Yes (17) | |
| 1.4 | Is there a mandatory universal screening policy in place? If yes, does the policy require screening of all women: (choose one) |
__No (0) | __Yes (0) |
| a) in the emergency department (ED) or any other out-patient area? | __Yes (6) | ||
| b) in in-patient units only? | or | __Yes (6) | |
| c) in more than one out-patient area? | or | __Yes (10) | |
| d) in both in-patient and out-patient areas? | or | __Yes (14) | |
| 1.5 | Are there administrative enforcement procedures in place to ensure domestic
violence screening? If yes, are there: |
__No (0) | __Yes (0) |
| a) regular chart audits to assess screening? | __No (0) | __Yes (6) | |
| b) positive reinforcers to promote screening? | __No (0) | __Yes (4) | |
| c) punitive measures for lack of screening? | __No (0) | __Yes (5) | |
| 1.6 | Are there procedures for security measures to be taken when victims of
domestic violence are identified? If yes, are there: |
__No (0) | __Yes (0) |
| a) written procedures that outline the security department's role in working with victims and perpetrators? | __No (0) | __Yes (6) | |
| b) procedures that include name/phone block for victims admitted to hospital? | __No (0) | __Yes (3) | |
| c) procedures that include provisions for safe transport from the hospital to shelter? | __No (0) | __Yes (3) | |
| 1.7 | Is there an identifiable domestic violence coordinator at the hospital? If yes is it a: (choose one) |
__No (0) | __Yes (0) |
| a) part time position or included in responsibilities of someone with other responsibilities? | __Yes (8) | ||
| b) full-time position with no other responsibilities? | or | __Yes (12) | |
| Total Score for Category 1 (Sum of all points) = | |||
| Category No. | Question | No | Yes |
|---|---|---|---|
| 2.1 | Are there posters and/or brochures related to domestic violence on public display in the hospital? | __No (0) | __Yes (0) |
| If yes, list total number of locations (up to 35): | (____) | ||
| 2.2 | Is there referral information (local, State, or national phone numbers) related to domestic violence services on public display in the hospital? (Can be included on the posters/brochure noted above). | __No (0) | __Yes (0) |
| If yes, list total number locations (up to 35): | __No (0) | (____) | |
| 2.3 | Does the hospital provide temporary (<24 hours) safe shelter for victims of domestic violence who cannot go home or cannot be placed in a community-based shelter? If yes: (choose one) |
__No (0) | __Yes (0) |
| a) Victims are permitted to stay in ED until placement is secured. | __Yes (15) | ||
| b) Victims are provided with safe respite room, separate from ED, until placement is secured. | or | __Yes (25) | |
| c) In-patient beds are available for victims until placement is secured. | or | __Yes (30) | |
| Total Score for Category 2 (Sum of all points) = | |||
| Category No. | Question | No | Yes |
|---|---|---|---|
| 3.1 | In the last 3 years, has there been a formal (written) assessment of the hospital staff's knowledge and attitude about domestic violence? If yes, which groups have been assessed? |
__No (0) | __Yes (0) |
| a) nursing staff | __No (0) | __Yes (7) | |
| b) medical staff | __No (0) | __Yes (7) | |
| c) administration | __No (0) | __Yes (8) | |
| d) other staff/employees | __No (0) | __Yes (7) | |
| 3.2 | How long has the hospital's domestic violence program been in existence? (Choose one): | ||
| a) 1-24 months | __Yes (3) | ||
| b) 24-48 months | or | __Yes (6) | |
| c) >48 months | or | __Yes (11) | |
| 3.3 | Does the hospital have plans in place for responding to employees experiencing domestic violence? If yes: | __No (0) | __Yes (0) |
| a) Is there a hospital policy covering the topic of domestic violence in the workplace? | __No (0) | __Yes (7) | |
| b) Does the Employee Assistance Program maintain specific policies and procedures for dealing with employees experiencing domestic violence? | __No (0) | __Yes (7) | |
| c) Is the topic of domestic violence among employees covered in the hospital training sessions and/or orientation? | __No (0) | __Yes (7) | |
| 3.4 | Does the hospital's domestic violence program address cultural competency issues? If yes: | __No (0) | __Yes (0) |
| a) Does the hospital's policy specifically recommend universal screening regardless of the patient's cultural background? | __No (0) | __Yes (6) | |
| b) Are cultural issues discussed in the hospital's domestic violence training program? | __No (0) | __Yes (6) | |
| c) Are translators/interpreters available for working with victims if English is not the victim's first language? | __No (0) | __Yes (3) | |
| d) Are referral information and brochures related to domestic violence available in languages other than English? | __No (0) | __Yes (4) | |
| 3.5 | Does the hospital participate in preventive outreach and public education activities on the topic of domestic violence? If yes, is there documentation of: (choose one) |
__No (0) | __Yes (0) |
| a) 1 program in the last 12 months? | __Yes (15) | ||
| b) >1 program in the last 12 months? | or | __Yes (20) | |
| Total Score for Category 3 (Sum all points) = | |||
| Category No. | Question | No | Yes |
|---|---|---|---|
| 4.1 | Has a formal training plan been developed for the institution? If yes: | __No (0) | __Yes (10) |
| a) Does the plan include the provision of regular, ongoing education for clinical staff? | __No (0) | __Yes (10) | |
| b) Does the plan include the provision of regular, ongoing education for non-clinical staff? | __No (0) | __Yes (10) | |
| 4.2 | During the past 12 months, has the hospital provided training on domestic violence: | ||
| a) as part of the mandatory orientation for new staff? | __No (0) | __Yes (15) | |
| b) to members of the medical staff via grand rounds or other sessions? | __No (0) | __Yes (15) | |
| 4.3 | Does the hospital's training/education on domestic violence include information about: | ||
| a) definitions of domestic violence? | __No (0) | __Yes (1) | |
| b) dynamics of domestic violence? | __No (0) | __Yes (1) | |
| c) epidemiology? | __No (0) | __Yes (1) | |
| d) health consequences? | __No (0) | __Yes (1) | |
| e) strategies for screening? | __No (0) | __Yes (1) | |
| f) assessment? | __No (0) | __Yes (1) | |
| g) documentation? | __No (0) | __Yes (1) | |
| h) intervention? | __No (0) | __Yes (1) | |
| i) safety planning? | __No (0) | __Yes (1) | |
| j) community resources? | __No (0) | __Yes (1) | |
| k) reporting requirements? | __No (0) | __Yes (1) | |
| l) legal issues? | __No (0) | __Yes (1) | |
| m) confidentiality? | __No (0) | __Yes (1) | |
| n) cultural competency? | __No (0) | __Yes (1) | |
| o) clinical signs/symptoms? | __No (0) | __Yes (1) | |
| 4.4 | Is the domestic violence training provided by: (choose one) | ||
| a) no training provided | __Yes (0) | ||
| b) a single individual? | or | __Yes (10) | |
| c) a team of hospital employees only? | or | __Yes (15) | |
| d) a team, including community expert(s)? | or | __Yes (25) | |
| Total Score for Category 4 (Sum all points) = | |||
| Category No. | Question | No | Yes |
|---|---|---|---|
| 5.1 | Does the hospital use a standardized instrument, with at least 3 questions, to screen patients for domestic violence? If yes, is this instrument: (choose one) |
__No (0) | __Yes (0) |
| a) included, as a separate form, in the clinical record? | __Yes (20) | ||
| b) incorporated as questions in the clinical record for all charts in ED or other out-patient area? | or | __Yes (25) | |
| c) incorporated as questions in the clinical record for all charts in two or more out-patient areas? | or | __Yes (30) | |
| d) incorporated as questions in clinical record for all charts in out-patient and in-patient areas? | or | __Yes (36) | |
| 5.2 | What percentage of eligible patients have documentation of domestic violence screening (based upon random sample of charts in any clinical area)? | ||
| a) Not done or not applicable | __Yes (0) | ||
| b) 0% - 10% | or | __Yes (4) | |
| c) 11% - 25% | or | __Yes (9) | |
| d) 26% - 50% | or | __Yes (18) | |
| e) 51% - 75% | or | __Yes (28) | |
| f) 76% - 100% | or | __Yes (37) | |
| 5.3 | Is a standardized safety assessment performed and discussed with victims who screen positive for domestic violence? | __No (0) | __Yes (27) |
| Total Score for Category 5 (Sum all points) = | |||
| Category No. | Question | No | Yes |
|---|---|---|---|
| 6.1 | Does the hospital use a standardized documentation instrument to record known or suspected cases of domestic violence? If yes, does the form include: |
__No (0) | __Yes (0) |
| a) information on the results of domestic violence screening? | __No (0) | __Yes (10) | |
| b) the victim's description of current and/or past abuse? | __No (0) | __Yes (10) | |
| c) the name of the alleged perpetrator and relationship to the victim? | __No (0) | __Yes (10) | |
| d) a body map to document injuries? | __No (0) | __Yes (10) | |
| e) information documenting the referrals provided to the victim? | __No (0) | __Yes (10) | |
| 6.2 | Is forensic photography incorporated in the documentation procedure? If yes: |
__No (0) | __Yes (0) |
| a) Is a fully operational camera with adequate film available in the treatment area? | __No (0) | __Yes (10) | |
| b) Do hospital staff receive on-going training on the use of the camera? | __No (0) | __Yes (10) | |
| c) Do hospital staff routinely offer to photograph all abused patients with injuries? | __No (0) | __Yes (10) | |
| d) Is a specific, unique consent-to-photograph form obtained prior to photographing any injuries? | __No (0) | __Yes (10) | |
| e) Do medical or nursing staff (not social work or a DV advocate) photograph all injuries for medical documentation purposes, even if police obtain their own photographs for evidence purposes? | __No (0) | __Yes (10) | |
| Total Score for Category 6 (Sum all points) = | |||
| Category No. | Question | No | Yes |
|---|---|---|---|
| 7.1 | Is there a standard intervention checklist for staff to use/refer to when victims are identified? | __No (0) | __Yes (14) |
| 7.2 | Are "on-site" victim advocacy services provided? If yes, choose one: |
__No (0) | __Yes (0) |
| a) A trained victim advocate provides services during certain hours. | __Yes (10) | ||
| b) A trained victim advocate provides service at all times. | or | __Yes (20) | |
| 7.3 | Are mental health/psychological assessments performed within the context of the program? If yes, are they: (choose one) |
__No (0) | __Yes (0) |
| a) available, when indicated? | __Yes (5) | ||
| b) performed routinely? | or | __Yes (9) | |
| 7.4 | Is transportation provided for victims, if needed? | __No (0) | __Yes (10) |
| 7.5 | Does the hospital domestic violence program include follow-up contact and counseling with victims after the initial assessment? | __No (0) | __Yes (15) |
| 7.6 | Does the hospital domestic violence program offer and provide on-site legal options counseling for victims? | __No (0) | __Yes (9) |
| 7.7 | Does the hospital domestic violence program offer and provide domestic violence services for the children of victims? | __No (0) | __Yes (11) |
| 7.8 | Is there evidence of coordination between the hospital domestic violence program and sexual assault, mental health and substance abuse screening and treatment? | __No (0) | __Yes (12) |
| Total Score for Category 7 (Sum all points) = | |||
| Category No. | Question | No | Yes |
|---|---|---|---|
| 8.1 | Are any formal evaluation procedures in place to monitor the quality of the domestic violence program? If yes: | __No (0) | __Yes (25) |
| a) Do evaluation activities include periodic monitoring of charts to audit for domestic violence screening? | __No (0) | __Yes (18) | |
| b) Do evaluation activities include peer-to-peer case reviews around domestic violence? | __No (0) | __Yes (17) | |
| 8.2 | Do health care providers receive standardized feedback on their performance and on patients? | __No (0) | __Yes (21) |
| 8.3 | Is there any measurement of client satisfaction and/or community satisfaction with the domestic violence program? | __No (0) | __Yes (19) |
| Total Score for Category 8 (Sum all points) = | |||
| Category No. | Question | No | Yes |
|---|---|---|---|
| 9.1 | Does the hospital collaborate with local domestic violence programs? If yes, which types of collaboration apply: |
__No (0) | __Yes (0) |
| a) collaboration with training? | __No (0) | __Yes (10) | |
| b) collaboration on policy and procedure development? | __No (0) | __Yes (10) | |
| c) collaboration on DV task force? | __No (0) | __Yes (10) | |
| d) collaboration on site service provision? | __No (0) | __Yes (12) | |
| 9.2 | Does the hospital collaborate with local law enforcement agencies in conjunction with their DV program? If yes, which types of collaboration apply: |
__No (0) | __Yes (0) |
| a) collaboration with training? | __No (0) | __Yes (11) | |
| b) collaboration on policy and procedure development? | __No (0) | __Yes (11) | |
| c) collaboration on DV task force? | __No (0) | __Yes (12) | |
| 9.3 | Is there collaboration with the domestic violence program of other health care facilities? If yes, which types of collaboration apply: |
__No (0) | __Yes (0) |
| a) within the same health care system? | __No (0) | __Yes (12) | |
| b) with other systems in the region? | __No (0) | __Yes (12) | |
| Total Score for Category 9 (Sum all points) = | |||