Medicolegal Death Investigation System: Workshop Summary (2003)

Garry Peterson

NAME began development of its accreditation process when the organization was formed in the 1960s. It recognized the importance of accreditation and quality assurance because of the isolation of most forensic pathology offices. By 1975, the first inspections by NAME were accomplished, and the accreditation process was revised to a checklist format in 1995.

The 1995 checklist contains 294 questions covering 13 topics: facilities; safety; personnel; notification, acceptance, and release; investigations; body handling; postmortem examinations; identification; evidence and specimen collection; support services²; reports and records; mass-disaster plan; and quality assurance.

NAME selects individuals who are required to work in a NAME-accredited office and take specific training before qualifying

as inspectors. Inspectors scrutinize facilities and provide a report to NAME for accreditation. Deficiencies cited by the inspectors can be of two types: phase 1 deficiencies, which are less serious; and phase 2 deficiencies, which bar accreditation (for example, if a medical examiner performs more than 350 autopsies per year). Full accreditation lasts 5 years. Provisional accreditation is possible if deficiencies are corrected within 1 year (and is renewable each year over the next 5 years). NAME views its accreditation process as a catalyst for improving offices throughout the country. But unlike hospital accreditation by the Joint Commission on Accreditation of Healthcare Organizations, for example, accreditation by NAME is not a requirement for funding of medical examiner and coroner offices.

Steven C. Clark

In 1998, NIJ promulgated the first guidelines for death-scene investigations. The publication was the culmination of a 5-year process that had been triggered by a national needs-assessment survey: in 1994, 60% of medical examiners and coroners had reported their dissatisfaction or extreme dissatisfaction with the level of investigative service that they received, either externally or internally. CDC and NIJ funded the development of the guidelines. The guidelines were reviewed by the National Medicolegal Review Panel, a review group of 263 members in 46 states. The guidelines cover 29 specific kinds of duties and 148 tasks.

To translate the guidelines into action, performance criteria for each were established. A trainer curriculum was later developed and implemented at instructor-training academies. The purpose of the academies was to establish a core of certified trainers skilled in both investigative and pedagogic skills. The academies also offer continuing education to medical examiners, coroners, and law-enforcement personnel.

When the guidelines were tested on 100 coroners and deputy coroners in Indiana, researchers from Occupational Research and Assessment, Inc. found that nearly 80% failed the examination. The dismal results prompted Indiana to mandate training programs for death-scene investigation. Later tests in other states revealed similar

failure rates. Coroners with medical backgrounds (other than forensic pathologists) performed as inadequately as did coroners.

Ross E. Zumwalt

Formal programs in quality assurance for medical examiner practice are in their infancy. Most states do not require quality assurance in statute or regulation. A review of 2000 articles in forensic professional journals revealed only one article on the topic; it was a proposal for an autopsy-protocol review rather than a formal evaluation of a quality-assurance program.

NAME accreditation requires a quality-assurance program, but it does not specify the type of program. It merely requires a written policy or standard operating procedure that is scheduled and implemented regularly, with documentation of corrective action for identified deficiencies. The American College of Pathology and the American Society of Clinical Pathology have various types of exercises for individual pathologists. They typically consist of several case histories, microscopic slides, and questions to answer. But these efforts are voluntary and infrequently used.

More systematic efforts are needed for in-house evaluation. The two most common methods are conference reviews and random case reviews. Conference reviews are regularly scheduled conferences held to discuss difficult cases. An interested pathologist presents a case, and then it is discussed. Some offices vote on the determination of death and keep logs of the case reviews.

A more valuable direction is random case reviews, which are endorsed by NAME. Random case reviews can be accomplished by a group or by an individual, anonymously or not. A pathologist other than the one who worked on the case reviews the entire case filethe autopsy report, the microscopic slides, x-ray pictures, police reports, and medical records. Then he or she fills out a checklist and gives the form to the pathologist who performed the original autopsy. However, there is no method for assessing the effectiveness of this program, that is, whether the reviews improve the quality of investigations.

One possible mechanism for quality assessment is case-type reviews. Similar cases are grouped according to cause of death (such as drug-related deaths or drowning) to determine how consistently they are handled. Another mechanism is an undetermined-cause-of-death review, in which an office takes every case of an undetermined cause of death and assigns it for review.

The overarching barrier to professionalism and quality, according to several participants, is budgetary. Lean budgets leave insufficient funding for training and for programs in quality assurance. An office’s budget is the most important determinant of the number of autopsies that it performs in a given yearnot the scientific evidence from the scene (Steven Clark, Vincent Di Maio, Kris Sperry).

The discussion focused on ways to promote greater commitment to quality assurance, especially for coroner offices that lack NAME accreditation, including

• Setting up a dedicated fund for training by charging the public $1-2 per death certificate (Steven Clark, Mary Fran Ernst).

• Promoting professional partnerships across small offices in remote locations with offices that more well-staffed (Ross Zumwalt).

• Raising awareness by challenging incumbent coroners’ lack of training during county elections (Steven Clark).

• Encouraging states to require coroners and medical examiners to complete training courses, and to set up a coroners-training board with responsibility for maintaining standards (Steven Clark).

A final discussion item focused on the type of quantitative outcome measures that could be used to evaluate the efficacy of quality-assurance programs. One approach was case-type reviews (such as accidents or electrocutions) that compare each case type with an office's own guidelines for that type. Several participants did not feel that winning or losing a legal case would be a good outcome measure of a quality-assurance program (Kurt Nolte, Garry Peterson).