{"text_format":"1","workbook":"xlsx","n_sheets":14,"sheets":["Form Overview","Instructions and Help","Evaluation Results","1. Organisational Leadership","2.Training and Support","3. Resource Funding","4. VIP Practices","5. Cultural Responsiveness","6. Quality Improvement","7. Policies and procedures "," 8. Collaboration","9. Documentation","Measurement Notes Summary","Item Standardised Score SPSS"],"not_rendered":{"charts":0,"images":3,"macros":1,"external_links":0,"defined_names":5,"comments":10,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Form Overview","index":0,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Instructions and Help","index":1,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Evaluation Results","index":2,"n_rows":21,"n_cols":6,"rows_kept":21,"cut":false,"hidden":false,"merged":[]}
[]
[]
[]
[]
[]
[null,null,"Domain","Score out of 100"," Weight ","Standardised  Score"]
[null,null,"1. Organisational leadership",{"$f":"'1. Organisational Leadership'!J39","v":{"$error":"#DIV/0!"}},0.14000000000000001,{"$f":"D7/100*E7","v":{"$error":"#DIV/0!"}}]
[null,null,"2. Training and support",{"$f":"'2.Training and Support'!J18","v":0},0.11799999999999999,{"$f":"D8/100*E8","v":0}]
[null,null,"3. Resource funding",{"$f":"'3. Resource Funding'!J14","v":0},0.115,0]
[null,null,"4. VIP practices",{"$f":"'4. VIP Practices'!J15","v":{"$error":"#DIV/0!"}},0.11,{"$error":"#DIV/0!"}]
[null,null,"5. Cultural responsiveness",{"$f":"'5. Cultural Responsiveness'!J29","v":0},0.109,0]
[null,null,"6. Quality improvement",{"$f":"'6. Quality Improvement'!J21","v":0},0.108,0]
[null,null,"7. Policies and procedures",{"$f":"'7. Policies and procedures '!J14","v":0},0.106,0]
[null,null,"8. Collaboration",{"$f":"' 8. Collaboration'!J32","v":0},0.105,0]
[null,null,"9. Documentation",{"$f":"'9. Documentation'!J14","v":0},8.7999999999999995E-2,0]
[]
[null,null,"Overall VIP evaluation score out of 100",{"$f":"SUM(F7:F15)*100","v":{"$error":"#DIV/0!"}},null,{"$f":"SUM(F7:F15)","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Form completed by:"]
[null,null,"Te Whatu Ora District"]
[null,null,"Date (dd/mm/yy):"]

{"sheet":"1. Organisational Leadership","index":3,"n_rows":39,"n_cols":11,"rows_kept":39,"cut":false,"hidden":false,"merged":[[38,2,38,5],[29,3,29,5],[6,2,6,3],[17,3,17,5],[8,3,8,5],[24,3,24,5]]}
[]
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[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence ","Points","Out of:","Item points  ","Your points","Links to resources"]
[null,null,1,"There is a governance group with clearly defined roles and responsibilities for strategic leadership of the Violence Intervention Programme (VIP).",null,null,{"$f":"IF(E8=\"Yes\",1,0)","v":0},1,11,{"$f":"I8*(G8/H8)","v":0}]
[null,null,2,"The following people with family violence understanding  are active participants in the VIP governance group:   "]
[null,null,2.1,"At least one member of Te Whatu Ora Executive Leadership Team ",null,null,{"$f":"IF(E10=\"Yes\",1,0)","v":0},1,2,{"$f":"I10*(G10/H10)","v":0}]
[null,null,2.2000000000000002," At least one core professional leader ",null,null,0,1,2,0]
[null,null,2.2999999999999998,"At least one directorate leader (or equivalent) from corporate services ",null,null,0,1,2,0]
[null,null,2.4," A Māori leader within Te Whatu Ora or community",null,null,0,1,2,0]
[null,null,2.5,"Senior manager(s) responsible for services implementing VIP",null,null,0,1,2,0]
[null,null,2.6,"Senior VIP team member ",null,null,0,1,2,0]
[null,null,3,"There is a two-way communication pathway between the governance group and the VIP team (includes VIP sponsor, VIP manager(s) and family violence intervention programme coordinator (FVIPC)).",null,null,0,1,14,0]
[null,null,4,"Consistent with interagency Memorandum of Understanding (MoU), there are at least biannual meetings at the senior leadership level on children at risk between Te Whatu Ora, Police and  Oranga Tamariki.",null,null,{"$f":"IF(E17=\"Both\",2,IF(E17=\"Oranga Tamariki\",1,IF(E17=\"Police\",1,0)))","v":0},2,11,0,"https://media.starship.org.nz/memorandum-of-understanding-child-protection/MOU_2022.pdf"]
[null,null,5,"Executive leadership of VIP demonstrated by:"]
[null,null,5.0999999999999996,"Regional or District key planning documents specify the VIP. ",null,null,{"$f":"IF(E19=\"Yes\",1,0)","v":0},1,2,{"$f":"I19*(G19/H19)","v":0}]
[null,null,5.2,"VIP status reporting to Health New Zealand|Te Whatu Ora Regional Deputy Chief Executive at least annually.",null,null,0,1,2,0]
[null,null,5.3,"VIP contract deliverables and KPIs reported to district leadership quarterly.",null,null,0,1,2,0]
[null,null,5.4,"Current, endorsed Te Whatu Ora policy that includes compulsory 8 hour VIP core training for all clinical staff in designated services.",null,null,0,1,2,0]
[null,null,5.5,"Implementing and monitoring the key performance indicators (KPIs) reporting by services.",null,null,0,1,2,0]
[null,null,5.6,"Evidence of acting on non-attained KPI(s), noting recommendations for improvement, necessary resourcing and follow up.  ",null,null,0,1,2,0]
[null,null,6," Senior clinical leaders communicate the expected VIP standard of clinical practice to their professional group(s) "]
[null,null,6.1,"Clinical Director (Chief Medical Officer)",null,null,{"$f":"IF(E26=\"Yes\",1,0)","v":0},1,1.5,{"$f":"I26*(G26/H26)","v":0}]
[null,null,6.2,"Director of Nursing",null,null,{"$f":"IF(E27=\"Yes\",1,0)","v":0},1,1.5,{"$f":"I27*(G27/H27)","v":0}]
[null,null,6.3,"Director of Midwifery",null,null,{"$f":"IF(E28=\"Yes\",1,0)","v":0},1,1.5,{"$f":"I28*(G28/H28)","v":0}]
[null,null,6.4,"Director of Allied Health",null,null,{"$f":"IF(E29=\"Yes\",1,0)","v":0},1,1.5,{"$f":"I29*(G29/H29)","v":0}]
[null,null,7,"Service Leaders report on the following key performance indicators (KPIs) to their senior managers at least quarterly.",null,null,null,null,null,null,"District VIP Managers Drop Box: Generic Service Spec documents"]
[null,null,"7a"," Please enter how many of the six designated services the Te Whatu Ora district provides.",null,null,{"$f":"E31","v":0}]
[null,null,7.1,"How many of the services report the proportion of staff trained in VIP? ",null,null,{"$f":"E32","v":0},{"$f":"G31","v":0},3,{"$f":"I32*(G32/H32)","v":{"$error":"#DIV/0!"}}]
[null,null,7.2,"How many of the services report  on the number  of VIP clinical champions?      ",null,null,{"$f":"E33","v":0},{"$f":"G31","v":0},3,{"$error":"#DIV/0!"}]
[null,null,7.3,"How many of the services report  on assessment and intervention compliance with  policy?",null,null,0,{"$f":"G31","v":0},3,{"$error":"#DIV/0!"}]
[null,null,7.4,"How many of the services report  on actions taken to address any non-compliance? ",null,null,0,{"$f":"+G31","v":0},3,{"$error":"#DIV/0!"}]
[null,null,8,"The implications of Te Whatu Ora initiatives on VIP service delivery where relevent are considered  (e.g, design, documentation forms, alert systems).",null,null,{"$f":"IF(E36=\"Yes\",1,0)","v":0},1,11,0]
[null,null,9,"At least 80% of senior leaders have received VIP training in the past two years. This includes VIP sponsor, governance group members, and senior executives of targeted VIP services. ",null,null,{"$f":"IF(E37=\"Yes\",1,0)","v":0},1,11,0]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,null,{"$f":"SUM(I8:I37)","v":100},{"$f":"SUM(J8:J37)","v":{"$error":"#DIV/0!"}}]

{"sheet":"2.Training and Support","index":4,"n_rows":18,"n_cols":11,"rows_kept":18,"cut":false,"hidden":false,"merged":[[7,2,7,3],[17,2,17,6]]}
[]
[]
[]
[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence ","Points","Out of: ","Item points","Your points","Links to resources"]
[null,null,1," Te Whatu Ora VIP core training package and any updates have been signed off by the national training provider.",null,null,{"$f":"IF(E9=\"Yes\",1,0)","v":0},1,11,{"$f":"I9*(G9/H9)","v":0},"National guidelines for VIP training"]
[null,null,2,"Te Whatu Ora training programme has been observed by the national training provider in the past two years.",null,null,{"$f":"IF(E10=\"Yes\",1,0)","v":0},1,11,{"$f":"I10*(G10/H10)","v":0}]
[null,null,3,"There are positive reinforcement practices in place to encourage staff in designated services to conduct routine IPV enquiry and child protection assessment. ",null,null,{"$f":"IF(E11=\"None\",0,IF(E11=\"One practice\",1,IF(E11=\"Two or more\",2,0)))","v":0},2,13,0]
[null,null,4,"Follow-up support occurs within one week of training. ",null,null,0,1,13,0]
[null,null,5,"Information about the VIP is included in the orientation for all staff. ",null,null,0,1,13,0]
[null,null,6,"The family violence training programme inludes responsiveness to Māori and other priority population groups. ",null,null,0,1,13,0]
[null,null,7,"Staff are evaluated/surveyed on their knowledge and attitude to family violence and its impact on Māori.",null,null,0,1,13,0]
[null,null,8,"There are support services available for Te Whatu Ora staff who are impacted by family violence.",null,null,0,1,13,0]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,{"$f":"SUM(H9:H16)","v":9},100,{"$f":"SUM(J9:J16)","v":0}]

{"sheet":"3. Resource Funding","index":5,"n_rows":14,"n_cols":11,"rows_kept":14,"cut":false,"hidden":false,"merged":[[6,2,6,3],[13,2,13,6]]}
[]
[]
[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence ","Points","Out of:","Item points","Your points","Links to resources"]
[null,null,1,"Te Whatu Ora funding and any extra funding for VIP is spent on the programme and not diverted elsewhere.",null,null,{"$f":"IF(E8=\"Yes\",1,0)","v":0},1,22,{"$f":"I8*(G8/H8)","v":0}]
[null,null,1.1000000000000001,"There is extra funding provided for people and resources specifically to reduce the impact of family violence on Māori.",null,null,{"$f":"IF(E9=\"Yes\",1,0)","v":0},1,22,0]
[null,null,1.2,"There is allocated administrative resources and support for the VIP. ",null,null,{"$f":"IF(E10=\"Yes\",1,0)","v":0},1,12,0]
[null,null,2,"The family violence intervention programme coordinator (FVIPC) roles for IPV and CAN  are currently filled. ",null,null,{"$f":"IF(E11=\"BOTH\",2,IF(E11=\"CAN\",1,IF(E11=\"IPV\",1,0)))","v":0},2,22,0]
[null,null,2.1,"How many months in the past 12 months have all FVIC roles been filled? Please enter a number between 0 and 12.",null,null,{"$f":"(E12/12)","v":0},1,22,0]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,{"$f":"SUM(H8:H12)","v":6},{"$f":"SUM(I8:I12)","v":100},{"$f":"SUM(J8:J12)","v":0}]

{"sheet":"4. VIP Practices","index":6,"n_rows":15,"n_cols":11,"rows_kept":15,"cut":false,"hidden":false,"merged":[[5,2,5,3],[14,2,14,6]]}
[]
[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence ","Points","Out of: ","Item points  ","Your points","Link to resources"]
[null,null,1,"How many of the designated services reach the target of at least 80% IPV routine enquiry rate among eligible women. ",null,null,{"$f":"E7","v":0},{"$f":"'1. Organisational Leadership'!G31","v":0},14.286,{"$f":"I7*(G7/H7)","v":{"$error":"#DIV/0!"}},"VIP Snapshot website \n\nOR"]
[null,null,2,"How many of the designated services reach the target of at least 5% IPV disclosure rate.",null,null,{"$f":"E8","v":0},{"$f":"'1. Organisational Leadership'!G31","v":0},14.286,{"$error":"#DIV/0!"},"VIP QI clnical audit tool (in dropbox)"]
[null,null,3,"How many of the designated services reach the target of at least 90% of women who disclosure IPV have documented referral to a specialised service or agency.",null,null,{"$f":"E9","v":0},{"$f":"'1. Organisational Leadership'!G31","v":0},14.286,{"$error":"#DIV/0!"}]
[null,null,4,"A Child Protection Checklist is completed for all children under the age of two years who present to the Emergency Department.",null,null,{"$f":"IF(E10=\"Yes\",1,0)","v":0},1,14.286,0]
[null,null,5,"There is evidence of consultation with someone who has child protection specialist knowledge for all cases when child protection concerns are identified. ",null,null,0,1,14.286,0]
[null,null,6,"For all children in whom a Report of Concern (ROC) is made to Oranga Tamariki, child protection concerns are identified and safety plans documented in the health record.",null,null,0,1,14.286,0,"Family Violence Assessment and Intervention Guideline (2016)"]
[null,null,7,"Assessments of child safety are conducted for all children in the care of women who disclose IPV.",null,null,0,1,14.286,0,"IPV Disclosure document clinical audit (2022) in Dropbox "]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,{"$f":"SUM(H7:H13)","v":4},{"$f":"SUM(I7:I13)","v":100.002},{"$f":"SUM(J7:J13)","v":{"$error":"#DIV/0!"}}]

{"sheet":"5. Cultural Responsiveness","index":7,"n_rows":29,"n_cols":11,"rows_kept":29,"cut":false,"hidden":false,"merged":[[13,10,17,10],[28,2,28,6],[8,3,8,5],[13,3,13,4],[7,2,7,3]]}
[]
[]
[]
[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence ","Points","Out of: ","Item points  ","Your points","Links to resources"]
[null,null,1,"VIP policy and procedures emphasise cultural responsiveness and provide tailored support for individuals and their whānau when accessing VIP services."]
[null,null,1.1000000000000001,"Māori",null,null,{"$f":"IF(E10=\"Yes\",1,0)","v":0},1,3.5750000000000002,{"$f":"I10*(G10/H10)","v":0}]
[null,null,1.2,"Other cultures",null,null,{"$f":"IF(E11=\"Yes\",1,0)","v":0},1,3.5750000000000002,{"$f":"I11*(G11/H11)","v":0}]
[null,null,1.3,"Disabled ",null,null,{"$f":"IF(E12=\"Yes\",1,0)","v":0},1,3.5750000000000002,{"$f":"I12*(G12/H12)","v":0}]
[null,null,1.4,"Gender identity",null,null,{"$f":"IF(E13=\"Yes\",1,0)","v":0},1,3.5750000000000002,{"$f":"I13*(G13/H13)","v":0}]
[null,null,2,"Te Whatu Ora ensures delivering a culturally responsive VIP service and fostering culturally safe practices among staff, with a strong focus on meeting the needs of Māori.  Please list some ways this is evident."]
[null,null,2.1,"Cultural responsiveness of the service  is evident in VIP policy. ",null,null,{"$f":"IF(E15=\"Yes\",1,0)","v":0},1,3,{"$f":"I15*(G15/H15)","v":0}]
[null,null,2.2000000000000002,"Cultural responsiveness is included in VIP training. ",null,null,{"$f":"IF(E16=\"Yes\",1,0)","v":0},1,3,{"$f":"I16*(G16/H16)","v":0}]
[null,null,2.2999999999999998,"Cultural awareness of staff is assessed through staff surveys or guided conversations on their understanding and attitudes of family voilence and its impact for Māori.",null,null,{"$f":"IF(E17=\"Yes\",1,0)","v":0},1,3,{"$f":"I17*(G17/H17)","v":0}]
[null,null,2.4,"Quality improvement review of service response for Māori has been conducted.",null,null,{"$f":"IF(E18=\"Yes\",1,0)","v":0},1,5.3,{"$f":"I18*(G18/H18)","v":0}]
[null,null,3,"A whānau-centred response is followed when working with victims of family violence.  “Māori and their whānau remain the central focus of health professionals’ activities, involving them in planning and decision-making activities and when deciding which services are needed to achieve their goals. Identifies both the collective and individual whānau members.” (Wepa, 2015, p.242) ",null,null,{"$f":"IF(E19=\"Yes\",1,0)","v":0},1,14.3,{"$f":"I19*(G19/H19)","v":0},"Māori health Action Plan-Whakamaua"]
[null,null,null,"Please provide examples to support rating:  "]
[null,null,4,"The VIP team engages with Kaupapa Māori support agencies within the community for the purpose of Family Violence specific referrals.",null,null,{"$f":"IF(E21=\"Yes\",1,0)","v":0},1,14.3,{"$f":"I21*(G21/H21)","v":0}]
[null,null,null,"Provide examples:"]
[null,null,5,"The delivery of the service for Māori is evaluated by Māori using Kaupapa Māori evaluation methods to ensure it is culturally responsive and safe. ",null,null,{"$f":"IF(E23=\"Yes Māori led\",2,IF(E23=\"Yes\",1,0))","v":0},2,14.3,{"$f":"I23*(G23/H23)","v":0}]
[null,null,6,"Trained and approved health care interpreters with family violence training are available for translating for  individuals and family if English is not their first language. ",null,null,{"$f":"IF(E24=\"Yes\",1,0)","v":0},1,14.2,{"$f":"I24*(G24/H24)","v":0}]
[null,null,7,"Family violence resources are available and on display in Te Reo Māori. ",null,null,{"$f":"IF(E25=\"Yes\",1,0)","v":0},1,7.15,{"$f":"I25*(G25/H25)","v":0}]
[null,null,7.1,"Family violence resources are available and on display in other languages (not including English) that reflects Te Whatu Ora catchment demographic. ",null,null,{"$f":"IF(E26=\"Yes\",1,0)","v":0},1,7.15,{"$f":"I26*(G26/H26)","v":0}]
[null,null,null,"List languages: "]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,null,{"$f":"SUM(I10:I27)","v":100.00000000000001},{"$f":"SUM(J10:J26)","v":0}]

{"sheet":"6. Quality Improvement","index":8,"n_rows":21,"n_cols":11,"rows_kept":21,"cut":false,"hidden":false,"merged":[[20,2,20,6],[6,2,6,3]]}
[]
[]
[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence ","Points","Out of: ","Item points  ","Your points","Links to resources"]
[null,null,1,"VIP is included in the district Health NZ|Te Whatu Ora quality and risk strategic plan.",null,null,{"$f":"IF(E8=\"Yes\",1,0)","v":0},1,10,{"$f":"I8*(G8/H8)","v":0}]
[null,null,2,"There is a formal VIP quality improvement plan.",null,null,{"$f":"IF(E9=\"Yes\",1,0)","v":0},1,10,{"$f":"I9*(G9/H9)","v":0}]
[null,null,3,"Responsibility for acting on quality improvement findings is clearly outlined in VIP policy and formal strategic (family violence and child protection) quality improvement process plan.",null,null,{"$f":"IF(E10=\"Yes\",1,0)","v":0},1,10,{"$f":"I10*(G10/H10)","v":0}]
[null,null,4,"There is a regular formal process whereby the VIP evaluation and quality improvement findings are discussed, reviewed and acted on with respective services.",null,null,{"$f":"IF(E11=\"Yes\",1,0)","v":0},1,10,{"$f":"I11*(G11/H11)","v":0}]
[null,null,5,"Evaluation includes health care providers receiving feedback relevant to their involvement with the VIP.",null,null,0,1,10,0]
[null,null,6,"Patient/client or community agency feedback regarding VIP service delivery is gathered and analysed on a regular basis (at least annually). ",null,null,0,1,10,{"$f":"I13*(G13/H13)","v":0},"Community Agency Feedback"]
[null,null,7,"Staff in designated services where VIP is implemented are asked to provide feedback including ideas for programme enhancement in their services every two years.",null,null,0,1,10,0]
[null,null,8,"A Māori quality framework (such as Whānau Ora) is used by Health NZ|Te Whatu Ora leadership to evaluate whether services are effective for Māori.",null,null,0,1,10,{"$f":"I15*(G15/H15)","v":0},"Whānau Ora Health Impact Assessment"]
[null,null,8.1,"This process includes Māori health service team review of feedback and  recommendations for improving the VIP effectiveness for Māori.",null,null,0,1,10,0]
[null,null,8.1999999999999993,"Please provide examples of how the service’s effectiveness for Māori is evaluated?"]
[null,null,9,"There is evidence that changes have been made to the VIP within the past 12 months based on staff, community or user feedback, or audit findings.  ",null,null,0,1,10,{"$f":"I18*(G18/H18)","v":0},"Plan-Do-Study-Act Resource Pack"]
[null,null,9.1,"If no changes please explain why (e.g. feedback positive, no budget). If changes, please summarise what the feedback was, how it was sourced and what the changes were."]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,{"$f":"SUM(H8:H19)","v":10},{"$f":"SUM(I8:I19)","v":100},{"$f":"SUM(J8:J19)","v":0}]

{"sheet":"7. Policies and procedures ","index":9,"n_rows":14,"n_cols":11,"rows_kept":14,"cut":false,"hidden":false,"merged":[[6,2,6,3],[13,2,13,6]]}
[]
[]
[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence ","Points","Out of: ","Item points  ","Your points","Links to resources"]
[null,null,1,"Te Whatu Ora has documented policies and procedures on intimate partner  violence and child protection that are current and align with the Ministry of Health guideline.",null,null,{"$f":"IF(E8=\"Yes\",1,0)","v":0},1,20,{"$f":"I8*(G8/H8)","v":0},"VIP policies linked to Family Violence Intervention Guidelines"]
[null,null,2,"Te Whatu Ora family violence policies and procedures are aligned with current legislation and relevant national policy initiatives (e.g. MOUs)",null,null,{"$f":"IF(E9=\"Yes\",1,0)","v":0},1,20,{"$f":"I9*(G9/H9)","v":0},"https://tepunaaonui.govt.nz/resource"]
[null,null,3,"The policies and procedures are readily available to staff on the intranet (within 3 clicks). ",null,null,0,1,20,{"$f":"I10*(G10/H10)","v":0}]
[null,null,4,"All family violence policies and procedures have input and are endorsed by Māori leadership. ",null,null,0,1,20,0]
[null,null,5,"Additional safety and security measures are specified for suspected cases of child abuse and neglect with perceived immediate risk, and for adults who are identified as high risk or in imminent threat.",null,null,0,1,20,0]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,{"$f":"SUM(H8:H12)","v":5},{"$f":"SUM(I8:I12)","v":100},{"$f":"SUM(J8:J12)","v":0}]

{"sheet":" 8. Collaboration","index":10,"n_rows":32,"n_cols":11,"rows_kept":32,"cut":false,"hidden":false,"merged":[[6,2,6,3],[31,2,31,6],[7,3,7,5],[13,3,13,5],[17,3,17,5],[20,3,20,5],[25,3,25,5]]}
[]
[]
[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence ","Points","Out of: ","Item points  ","Your points","Link to resources"]
[null,null,1,"There is clear evidence that a Memorandum of Understanding (MOU) between Te Whatu Ora and  Oranga Tamariki and Police for child protection responses has been  operationalised by: ",null,null,null,null,null,null,"MOU examples and information"]
[null,null,1.1000000000000001,"Signing of MOU",null,null,{"$f":"IF(E9=\"Both\",2,IF(E9=\"Oranga Tamariki\",1,IF(E9=\"Police\",1,0)))","v":0},2,4.1675000000000004,{"$f":"I9*(G9/H9)","v":0}]
[null,null,1.2,"Regular meetings at service level with actions and accountability (at least biannual)",null,null,{"$f":"IF(E10=\"Both\",2,IF(E10=\"Oranga Tamariki\",1,IF(E10=\"Police\",1,0)))","v":0},2,4.1675000000000004,{"$f":"I10*(G10/H10)","v":0}]
[null,null,1.3,"Interagency review of cases",null,null,{"$f":"IF(E11=\"Both\",2,IF(E11=\"Oranga Tamariki\",1,IF(E11=\"Police\",1,0)))","v":0},2,4.1675000000000004,{"$f":"I11*(G11/H11)","v":0}]
[null,null,1.4,"Participation in or initiation of interagency training",null,null,{"$f":"IF(E12=\"Both\",2,IF(E12=\"Oranga Tamariki\",1,IF(E12=\"Police\",1,0)))","v":0},2,4.1675000000000004,{"$f":"I12*(G12/H12)","v":0}]
[null,null,2,"There is  evidence of Service Level Agreements  (SLA) between Te Whatu Ora and family violence services with regards to referrals and how on-site services will be provided. ",null,null,{"$f":"IF(E13=\"Yes\",1,0)","v":0},1,16.670000000000002,{"$f":"I13*(G13/H13)","v":0}]
[null,null,3,"Ongoing partnership between Te Whatu Ora and Māori service agencies or health providers, and/or local Iwi or Urban Māori Authority evidenced by:"]
[null,null,3.1,"Participation in, or initiation, of training (e.g. involvement in the VIP training at Te Whatu Ora)",null,null,{"$f":"IF(E15=\"1 Agency\",1,IF(E15=\"2+ Agencies\",2,0))","v":0},2,{"$f":"16.67/3","v":5.5566666666666675},{"$f":"I15*(G15/H15)","v":0}]
[null,null,3.2,"Policy review ",null,null,{"$f":"IF(E16=\"1 Agency\",1,IF(E16=\"2+ Agencies\",2,0))","v":0},2,{"$f":"16.67/3","v":5.5566666666666675},{"$f":"I16*(G16/H16)","v":0}]
[null,null,3.3,"Representation on the VIP governance group",null,null,{"$f":"IF(E17=\"1 Agency\",1,IF(E17=\"2+ Agencies\",2,0))","v":0},2,{"$f":"16.67/3","v":5.5566666666666675},{"$f":"I17*(G17/H17)","v":0}]
[null,null,4,"There is evidence of engagement and collaboration with external family violence services agencies at a senior management and operational VIP level. "]
[null,null,4.0999999999999996,"Senior management level (provide examples)",null,null,{"$f":"IF(E19=\"Yes\",1,0)","v":0},1,{"$f":"16.67/2","v":8.3350000000000009},{"$f":"I19*(G19/H19)","v":0}]
[null,null,4.2,"Operational VIP level (provide examples)",null,null,{"$f":"IF(E20=\"Yes\",1,0)","v":0},1,{"$f":"16.67/2","v":8.3350000000000009},{"$f":"I20*(G20/H20)","v":0}]
[null,null,5,"There is an MOU or SLA with the following agencies regarding the service delivery for victims of sexual assault (adults, adolescents and children). ",null,null,null,null,null,null,"Medical Sexual Assault Clinicians Aotearoa"]
[null,null,5.0999999999999996,"Police",null,null,{"$f":"IF(E22=\"Yes\",1,0)","v":0},1,4.1675000000000004,{"$f":"I22*(G22/H22)","v":0}]
[null,null,5.2,"ACC",null,null,{"$f":"IF(E23=\"Yes\",1,0)","v":0},1,4.1675000000000004,{"$f":"I23*(G23/H23)","v":0}]
[null,null,5.3,"Oranga Tamariki",null,null,{"$f":"IF(E24=\"Yes\",1,0)","v":0},1,4.1675000000000004,0]
[null,null,5.4,"Te Whatu Ora policies specify the pathway for service delivery including acute response and referral for sexual assault or suspected/alleged sexual abuse of a child.",null,null,{"$f":"IF(E25=\"Yes\",1,0)","v":0},1,4.1675000000000004,0]
[null,null,6,"At least two multiagency case reviews (one for IPV and one for CAN) have been undertaken in the last 12 months that evaluate health actions within family violence response. "]
[null,null,6.1,"At least 1 review for IPV?",null,null,{"$f":"IF(E27=\"Yes\",1,0)","v":0},1,{"$f":"16.67/2","v":8.3350000000000009},0]
[null,null,6.2,"At least 1 review for CAN?",null,null,{"$f":"IF(E28=\"Yes\",1,0)","v":0},1,{"$f":"16.67/2","v":8.3350000000000009},0]
[null,null,6.3,"How have findings been shared with Te Whatu Ora services? "]
[null,null,6.4,"How have recommendations been actioned?"]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,{"$f":"SUM(H8:H25)","v":21},{"$f":"SUM(I8:I30)","v":100.02000000000004},{"$f":"SUM(J8:J30)","v":0}]

{"sheet":"9. Documentation","index":11,"n_rows":14,"n_cols":11,"rows_kept":14,"cut":false,"hidden":false,"merged":[[7,2,7,3],[13,2,13,6]]}
[]
[]
[]
[]
[]
[]
[]
[null,null,"Item",null,"Response","Please provide evidence","Points","Out of: ","Item points  ","Your points","Link to resources"]
[null,null,1,"Standardised documentation instruments (or templates) that are aligned with the Ministry of Health FVAIG are used to record known or suspected cases of family violence.",null,null,{"$f":"IF(E9=\"Yes\",1,0)","v":0},1,10,{"$f":"I9*(G9/H9)","v":0},"Ministry of Health Family Violence Assessment and Intervention Guideline "]
[null,null,1.1000000000000001,"All IPV routine enquiry, disclosures and referrals are documented on the standardised templates (e.g. Intimate Partner Violence (IPV) Assessment and Intervention Documentation)",null,null,{"$f":"IF(E10=\"Yes\",1,0)","v":0},1,23.33,{"$f":"I10*(G10/H10)","v":0},"IPV Assessment and Intervention Documentation form (aligned with the FVAIG)"]
[null,null,2,"The national form (Report of Concern) is used for referral to Oranga Tamariki",null,null,{"$f":"IF(E11=\"Yes\",1,0)","v":0},1,33.299999999999997,{"$f":"I11*(G11/H11)","v":0}]
[null,null,3,"Patients with injuries caused by family violence are routinely offered a medical photography option, either in Te Whatu Ora or by the police. ",null,null,{"$f":"IF(E12=\"Yes\",1,0)","v":0},1,33.299999999999997,{"$f":"I12*(G12/H12)","v":0}]
[]
[null,null,"Domain Score (out of 100)",null,null,null,null,{"$f":"SUM(H9:H12)","v":4},{"$f":"SUM(I9:I12)","v":99.929999999999993},{"$f":"SUM(J9:J12)","v":0}]

{"sheet":"Measurement Notes Summary","index":12,"n_rows":95,"n_cols":4,"rows_kept":95,"cut":false,"hidden":false,"merged":[[70,0,74,0],[75,0,90,0],[91,0,94,0],[2,0,27,0],[28,0,35,0],[36,0,40,0],[41,0,47,0],[48,0,59,0],[60,0,69,0]]}
["Measurement Notes Summary Page (only items with measurement notes included here)"]
["Domain","Item",null,"Measurement Note"]
["Organisational Leadership","1","There is a governance group with clearly defined roles and responsibilities for strategic leadership of the Violence Intervention Programme (VIP).","The governance group (or steering committee/group) must focus on family violence at a programme strategy level, with accountability and vision. This must be evidenced in written documentation (e.g. Terms of Reference, agenda and meeting minutes). An operational group may also exist, but groups that focus solely on operational issues or case reviews do not qualify as a governance group. The group must have been convened at least twice in the past 12 months."]
[null,"2","The following people with family violence understanding  are active participants in the VIP governance group:","Evidence provided by the governance group member list and meeting minutes. To score a 'yes' the member needs to attend ≥50% of meetings in the past year or since joining the group as evidenced in meeting minutes, discussion and action points.  One person may be counted in more than one sub-item (e.g. the Director of Nursing may also sit on the Executive Leadership Team)."]
[null,"2.1","At least one member of Te Whatu Ora Executive Leadership Team.","Executive Leadership team members are generally listed on district websites."]
[null,"2.2","At least one core professional leader.","Such as Director of Nursing, Director of Midwifery, Chief Medical Officer or Director of Allied Health."]
[null,"2.3","At least one directorate leader (or equivalent) from corporate services","Such as from Quality and Risk, Funding & Planning or Human Resources."]
[null,"2.4","A Māori leader within Te Whatu Ora or community."]
[null,"2.5","Senior manager(s) responsible for services implementing VIP.","A minimum of one service senior manager to provide the senior service level manager perspective."]
[null,"2.6","Senior VIP team member","Such as sponsor or coordinator line manager. This does not preclude a coordinator(s) attending and participating in the governance group."]
[null,"3","There is a two-way communication pathway between the governance group and the VIP team (includes VIP sponsor, VIP manager(s) and family violence intervention programme coordinators).","Communication is two-way, including VIP input into the governance group and feeding back of strategy and decisions to the VIP team. Evidence from the past year that illustrates two-way communication which might include quarterly reports from the FVIC to the governance group,  emails from the governance group to the FVIC,  meeting minutes, tabling of reports and programme updates and recommendations."]
[null,"4","Consistent with interagency Memorandum of Understanding (MoU), there are at least biannual meetings at the senior leadership level on children at risk between Te Whatu Ora, Police and Oranga Tamariki.","Must discuss programme matters aligned with MoU in recognition of ‘the benefits of positive working relationships at regional and district levels’. Meeting notes, emails or calendar appointments could be used as evidence. See MoU – Oranga Tamariki, Police, DHB (page 4, ‘Meetings’)."]
[null,"5","Executive leadership of VIP demonstrated by:"]
[null,"5.1","Regional or District key planning documents specify VIP.","VIP and/or family violence (IPV/CAN) is specified in documents such as strategic or annual plan."]
[null,"5.2","VIP status reporting to Health New Zealand Te Whatu Ora Regional Deputy Chief Executive at least annually.","Evidenced by reporting documents or meeting minutes."]
[null,"5.3","VIP contract deliverables and KPIs are reported to district leadership quarterly.","This may be evidenced by report documentation, meeting agenda or minutes.  The reporting pathway may involve the VIP governance group. May be exception reporting."]
[null,"5.4","Current, endorsed Te Whatu Ora policy that includes compulsory 8 hour VIP core training for all clinical staff in designated services.","Must include that training is compulsory for all clinical staff in designated areas and that it must be a minimum of 8 hours."]
[null,"5.5","Implementing and monitoring the key performance indicators (KPIs) reporting by services.","This is the reporting on KPIs: proportion of staff trained, rates of IPV routine inquiry and referral, and rates of CAN assessment and identification of child protection needs and specialist consultation."]
[null,"5.6","Evidence of acting on non-attained KPI(s), noting recommendations for improvement, necessary resourcing and follow up.","In report, emails and meeting minutes showing actions against at least one non-attained KPI.  If all KPIs are attained then select 'yes'."]
[null,"6","Senior clinical leaders communicate the expected VIP standard of clinical practice to their professional group(s)","Within the last year, evidence that the clinical leader has clearly communicated expectations for attendance at training and implementation of policy.  Evidence may be located in meeting minutes, newsletters, KPIs or other.  These actions provide evidence of the senior clinical leader as a champion for the response to family violence as laid out in VIP. This is the list of clinical leaders that is scored but the list is not exhaustive, all clinical leaders would be expected to support VIP practice standards."]
[null,"7","Service Leaders report on the following key performance indicators (KPIs) to their senior managers at least quarterly.","This may include formal KPIs or informal indicators referenced in reports. If the KPI or indicator is mentioned in reporting—such as quarterly reports, email updates, or meeting agendas—it can be marked as \"Yes.\" This item assesses whether the KPI is being reported by service leaders, not whether the KPI target is achieved"]
[null,"7a","Please enter  how many of the six designated services the Te Whatu Ora district provides.","While most Te Whatu Ora districts provide all six designated services, some services may be contracted out or delivered regionally. Please enter the number of the following services that are directly provided by your district:  child health (inpatient); emergency department; community mental health; alcohol & other drug; sexual health; postnatal maternity."]
[null,"7.1","How many of the services report  on the proportion of staff trained in VIP?","Enter the number of designated services (among those identified in item 7a) where the service leader reports on this KPI."]
[null,"7.2","How many of the services report  on the number  of VIP clinical champions?","Enter the number of designated services (among those identified in item 7a) where the service leader reports on this KPI."]
[null,"7.3","How many of the services report  on assessment and intervention compliance with  policy?","Enter the number of designated services (among those identified in item 7a) where the service leader reports on this KPI."]
[null,"7.4","How many of the services report  on actions taken to address any non-compliance?","Enter the number of designated services (among those identified in item 7a) where the service leader reports on this KPI."]
[null,"8","The implications of Te Whatu Ora initiatives on VIP service delivery, where relevant, are considered  (e.g., design, documentation forms, alert systems).","Provide an example (in the evidence column) from within the past year. Consider how governance group members, the VIP sponsor, or a manager have acknowledged and responded to a new initiative or change that could impact responsiveness to family violence and the VIP programme. For example, when discussions around contracting a national interpreter service arise, a champion advocates for family violence training for all health interpreters to ensure safe and appropriate responses."]
[null,"9","At least 80% of senior leaders have received VIP training in the past two years. This includes\nVIP sponsor, governance group members; and senior executives of targeted VIP services.","Senior leaders must complete VIP training at least once every two years. This can be either the full-day core training or a tailored executive-level session. Review training records or meeting notes. Determine whether the number attended training divided by the total number of relevant senior leaders is ≥ 80%."]
["Training & Support","1","Te Whatu Ora VIP core training package and any updates have been signed off by the national training provider.","Evidenced by an email confirmation of sign-off by the national training provider. This is required every 2 years.  Core training package is updated by national trainers each year (and observed every two years)"]
[null,"2","Te Whatu Ora training programme has been observed by the national training provider in the past two years.","A national VIP trainer has conducted a training observation in the past two years. Evidenced by post-observation report to the district VIP team with feedback and recommendations."]
[null,"3","There are positive reinforcement practices in place to encourage staff in designated services to conduct routine IPV enquiry and child protection assessment.","Evidence should demonstrate that the reinforcement activity is part of a strategic approach to building a culture of family violence responsiveness rather than a one off. Supporting evidence may include performance review documents (e.g. appraisal forms with KPIs on IPV/CAN routine assessment and VIP training attendance), recognition by management (e.g. email), or VIP champion awards in newsletter or reports."]
[null,"4","Follow-up support occurs within one week of training.","For 'yes', evidence of face-to-face or email contact that directs staff to post-training support. This should include the names of the service VIP champions, referral and community partner contact information and relevant resources.  May also include, for example, a training book of 'takeaway tasks' to complete or a form that is signed-off and given to the VIP coordinator or the manager after VIP implementation."]
[null,"5","Information about VIP is included in  the orientation for all staff.","Evidence must show that VIP information is explicitly  included  in the orientation programme agenda or materials to promote awareness of the programme (including Te Whatu Ora policy) and resources. This may be presented during orientation sessions or provided in written materials."]
[null,"6","The family violence training programme includes responsiveness to Māori and other priority population groups.","Evidence from a review of training materials and discussions with training providers should demonstrate locally innovative training that is culturally responsive to Māori and addresses the diverse needs of priority groups, including Māori, Tangata Whaikaha, Pacific Peoples, and rainbow communities within the local population."]
[null,"7","Staff are evaluated/surveyed on their knowledge and attitude to family violence and its impact on Māori.","Requires documentation of assessing staff understanding of historical and ongoing negative impacts of colonisation on Māori and relationship to family violence. This could be included in a pre- or post-training evaluation survey to inform improvements in training and support, or kōrero during training session."]
[null,"8","There are support services available for Te Whatu Ora staff who are impacted by family violence.","To qualify for a 'yes' there is evidence of a free and confidential specialised service for staff that provides counselling or expertise in addressing family violence (for example, community services, national hotlines or family-violence trained EAP). Information about the service needs to be accessible to staff (included on intranet, in orientation and core training)."]
["Resource Funding","1","Te Whatu Ora funding and any extra funding for VIP is spent on the programme and not diverted elsewhere.","A VIP budget report documents the full allocation of NZ Health Te Whatu Ora contracted VIP funding has been spent on the programme over the last financial year. This should include funded VIP coordinator and their professional development."]
[null,"1.1","There is extra funding provided for people and resources specifically to reduce the impact of family violence on Māori.","This could be funding for cultural support services, or resources specifically for Māori and or in Te Reo with regards to family violence."]
[null,"1.2","There is allocated administrative resources and support for the VIP.","For a 'yes' there must be administrative support available with dedicated time to the VIP."]
[null,"2","The family violence intervention programme coordinator (FVIPC) roles for IPV and CAN are currently filled.","Please select for role/s currently filled (CAN, IPV or BOTH).  Some districts  may have only one combined IPV/CAN role.  If filled, select 'BOTH' and if not select 'NONE'."]
[null,"2.1","How many months in the past 12 months have all FVIC roles been filled? Please enter a number between 0 and 12.","Enter the number of months that all allocated FVIC roles (including joint, IPV, and/or CAN roles) were filled in your district over the past 12 months.\n*  If any role was vacant for the full year, enter '0'.\n*  If all roles were filled for the entire year, enter '12'.\n*  If a role was unfilled for part of the year, enter the number of months it was filled (between 1 and 11)."]
["VIP Practices","1","How many of the designated services reach the target of at least 80% IPV routine enquiry rate among eligible women. ","Of the number of designated services your district provides (as listed in the Organisational Leadership Domain item 7a, cell 31E), enter how many of the services reached the target of ≥ 80% IPV routine enquiry.\n• This should be a whole number between 0 and 6.\n\nPrioritise evidence from most recent clinical audit, either Snapshot audit, an updated standardised chart audit (e.g., using the VIP Excel QI clinical audit tool), or latest quarterly report (if digital data available).  "]
[null,"2","How many of the designated services reach the target of at least 5% IPV disclosure rate. ","In the clinical audits referenced in item 1 above, enter how many of the services reached the target of ≥ 5% IPV disclosure (among women assessed for IPV).\n•\tThis should be a whole number between 0 and 6."]
[null,"3","How many of the designated services reach the target of at least 90% of women who disclosure IPV have documented referral to a specialised service or agency.","In the clinical audits referenced in item 1 above, enter how many of the services reached ≥ 90% of women who disclose IPV have documented specialist referral (e.g. hospital or community social worker or agency such as women’s refuge or SHINE). \n•\tThis should be a whole number between 0 and 6.\n\nWhile our target is all women (100%) receive specialised service referral, we recognise that achieving this may not always be feasible. A minimum threshold of 90% is acceptable, though we encourage efforts toward achieving 100%. "]
[null,"4","A Child Protection Checklist is completed for all children under the age of two years who present to the Emergency Department.","Enter 'yes' if the rate of completed child protection checklist is ≥ 90% based on the most recent clinical emergency department child protection checklist audit.\n\nBecause child protection of children <2 years of age is a priority population, our target is 100% coverage; however, we recognise that achieving this may not always be feasible. A minimum threshold of 90% is acceptable, though we encourage efforts toward achieving 100%."]
[null,"5","There is evidence of consultation with someone who has child protection specialist knowledge for all cases when child protection concerns are identified.","From the emergency department clinical audit referenced in item 4 above, enter 'yes' if the rate of documented consultation with a specialist (such as emergency medical specialist, paediatrician, health social worker, Oranga Tamariki hospital liaison) when a concern is identified is ≥ 90%. \n\nWhile our target is 100%, we recognise that achieving this may not always be feasible. A minimum threshold of 90% is acceptable, though we encourage efforts toward achieving 100%."]
[null,"6","For all children in whom a Report of Concern (ROC) is made to Oranga Tamariki, child protection concerns are identified and safety plans documented in the health record","Review health records of children for whom a Report of Concern (ROC) was made to Oranga Tamariki for evidence that concerns were identified and safety plans documented.\nConcern and safety documentation aligns with the Family Violence\nAssessment and\nIntervention\nGuideline (2016), see Child Abuse and Neglect sections 1.3 and 1.4.\nWhile our target is 100%, audit data must meet a threshold of ≥90%."]
[null,"7","Assessments of child safety are conducted for all children in the care of women who disclose IPV.","Evidence must be drawn from the most recent review of IPV Documentation Forms (Risk Assessment document). Data may be collected using a bespoke spreadsheet or the VIP Quality Improvement IPV Disclosure clinical audit spreadsheet. While the target is 100%, audit data must meet a minimum threshold of ≥90%."]
["Cultural Responsiveness","1","VIP policy and procedures emphasise cultural responsiveness and provide tailored support for individuals and their whānau when accessing VIP services.","Evidenced through reference to the different groups in the written policies, procedures and training programmes so that the VIP approaches each situation with an awareness of individuals and their whānau needs based on ability, ethnicity, culture, gender identity and sexual orientation."]
[null,"2","Te Whatu Ora ensures delivering a culturally responsive VIP service and fostering culturally safe practices among staff, with a strong focus on meeting the needs of Māori.  Please list some ways this is evident.","Evidence of intent for culturally responsive services. Engagement with Māori partners or stakeholders within HSS and broader Te Whatu Ora (if necessary) to review VIP policy and practice noting that Māori world views, historical and contemporary, are included."]
[null,"2.1","Cultural responsiveness of the service is evident in VIP policy.","VIP policy refers specifically to responsiveness to Māori."]
[null,"2.2","Cultural responsiveness  is included in VIP training.","Māori models of health are integrated within VIP training and the VIP CORE training delivered locally has been evaluated (formally or informally) by local or regional Māori Health Advisor (or other) to ensure cultural responsiveness."]
[null,"2.3","Cultural awareness of staff is assessed through staff surveys or guided conversations on their understanding and attitudes towards family violence and its impact for Māori."]
[null,"2.4","Quality improvement review of service response for Māori is conducted.","Information is gathered in a culturally safe and appropriate manner, aligned with item 8 in the Quality Improvement domain. This includes, for example:  Engaging Māori individuals and communities in ways that uphold tikanga and respect Māori worldviews;  Partnering with Māori health providers to facilitate feedback, for example, through informal check-ins with wāhine or whānau who have interacted with the VIP service;   Ensuring that feedback mechanisms are inclusive, respectful, and responsive to the lived experiences of Māori;  Using culturally appropriate methods such as kanohi ki te kanohi (face-to-face) engagement, hui, or other forms of whakawhanaungatanga."]
[null,"3","A whānau-centred response is followed when working with victims of family violence.  “Māori and their whānau remain the central focus of health professionals’ activities, involving them in planning and decision-making activities and when deciding which services are needed to achieve their goals. Identifies both the collective and individual whānau members” (Wepa, 2015, p.242).","Review of policies, practices, and training in the VIP responsiveness to Māori (noting a whānau centred approach applicable to everyone). This may be evidenced by Māori Health expertise within HSS auditing the procedures or clinical notes to evaluate whānau centred response to Māori who receive routine inquiry and or disclose family violence. Patient survey data if available. Note the MoH FVAIG (pp. 19-26) highlights principles of action to effectively support Māori experiencing violence within their whānau."]
[null,"4","The VIP Coordinator engages with Kaupapa Māori support agencies within the community for the purpose of Family Violence specific referrals.","\"For a 'yes' there must be evidence of relationships, and contact information with different agency groups in the community. Can provide list of agencies that the programme has referred to, or that the FVIPC  has been in contact with in the past six months."]
[null,"5","The delivery of the service for Māori is evaluated by using Kaupapa Māori evaluation methods to ensure it is culturally responsive and safe.","To score a 'yes', there must be evidence that Māori have been asked for feedback on the VIP service in ways that are appropriate and safe for them.  This might include, for example, gathering feedback from community agencies working with Māori on the responsiveness of the VIP service."]
[null,"6","Māori Health Advisors and/or interpreters have been trained in family violence (IPV and CAN)  and are utilised to ensure communication in a language appropriate for the person and whānau.","To qualify for a 'yes' there must be evidence that interpreters/Māori Health Advisors are used when the patient or caregiver’s primary language is not English.  Evidence should include the procedure for accessing interpreters, trained in to interview on family violence and age and gender appropriate. Note that phone interpretation is accepted.  It is not a 'yes' if the interpreter is related to or a friend of the victim or caregiver."]
[null,"7","Family violence resources are available and on display in Te Reo Māori.","There should be visible information in Te Reo Māori (such as posters or brochures) in services that have implemented VIP, which refer to family violence and provide guidance on where to seek help."]
[null,"7.1","Family violence resources are available and on display in languages (not including English) that reflects Te Whatu Ora catchment demographic.","There should be information (e.g. posters or brochures) that refer to family violence and provide information on where to seek help in languages that reflect the catchment population."]
["Quality Improvement","1","VIP is included in the district Health NZ| Te Whatu Ora quality and risk strategic plan.","A review of the regional or district quality and risk programme plan mentions the VIP. To qualify for 'yes' it must be seen as a specific programme plan. This signals that improving responsiveness to family violence is a shared activity and doesn’t sit solely with the VIP coordinator."]
[null,"2","There is a formal VIP quality improvement plan.","The plan may be stand alone or be included in an annual VIP strategic plan, supported by the Governance Group. \nThe plan is ideally informed by identified gaps in the system evidenced through service user, community or staff feedback or delphi or snapshot audits findings.  Seek assistance from VIP Sponsor, Governance Group or Quality & Risk directorate."]
[null,"3","Responsibility for acting on quality improvement findings is clearly outlined in VIP policy and formal strategic (family violence and child protection) quality improvement process plan.","A review of the VIP policies or quality improvement plan provides evidence of who is responsible for programme improvement."]
[null,"4","There is a regular formal process whereby the VIP evaluation and quality improvement findings are discussed, reviewed and acted on with respective services.","Evidence must show that findings are  regularly reviewed and acted upon as part of a quality improvement process (e.g. biannual or annual review). This includes documentation outlining the process, frequency, types of input considered, and who is involved. Examples of acceptable evidence include:\nAn annual meeting between FVIPC and clinical sponsors to review findings with recommendations discussed and agreed upon.\nDiscussions held at governance group meetings with documented outcomes.\nThis demonstrates that improving responsiveness to family violence is a shared responsibility and not solely the role of the VIP coordinator."]
[null,"5","Evaluation includes health care providers receiving feedback relevant to their involvement with the VIP.","There is evidence of the regular provision of feedback by the FVIPC or service manager to health care providers.  This may include feedback on routine assessment, chart documentation, and outcomes associated with recent VIP cases, peer-to-peer case reviews and acknowledgement of positive practice and policy compliance."]
[null,"6","Patient/client or community agency feedback regarding VIP service delivery is gathered and analysed on a regular basis (at least annually).","Evidence that feedback is received from community agencies.  The feedback could be gathered through interviews, review meetings or hui as evidenced in email, meeting agendas or minutes. For example, an agency may present feedback at a Governance Group meeting. This item can also be met if initiating a PDSA to gather client feedback, for example, about the IPV routine enquiry process."]
[null,"7","Staff in designated services where VIP is implemented are asked to provide feedback including ideas for programme enhancement in their services every two years.","Evidence that staff have been asked for feedback on the VIP in the past 2 years (e.g. through an online survey, staff meetings, or a comment/suggestion box)."]
[null,"8","A Māori quality framework (such as Whānau Ora) is used by Health NZ|Te Whatu Ora leadership to evaluate whether services are effective for Māori.","Could be evidenced through an audit by the district Māori health service team (structures and names will vary by locality, such as Takawaenga or He Kāmaka Waiora) interviews/focus groups with Māori patients. To be completed in consultation with Māori and VIP Sponsor."]
[null,"8.1","This process includes Māori health service team review of feedback and  recommendations for improving the VIP effectiveness for Māori.","Evidence (e.g. reports, meeting or hui agendas, emails) that feedback or recommendations on VIP delivery is reviewed by the Māori Health service team  to ensure appropriateness of the programme for Māori."]
[null,"9","There is evidence that changes have been made to the VIP within the past 12 months based on staff, community or user feedback, or audit findings.","Evidence that demonstrates a commitment to continuous improvement and responsiveness to feedback. Examples of acceptable evidence include:\nA PDSA initiative testing a small change or system ‘nudge’\nUpdates to training materials based on staff feedback\nIntroduction of paediatrician peer reviews."]
["Policies & Procedures","1",null,"Evidence of current policies (allowing a 6 month grace period)."]
[null,"2","Te Whatu Ora family violence policies and procedures are aligned with current legislation and relevant national policy initiatives (e.g. MOUs).","Evidence from a review of the policies and procedure documentation against the legislation (see Appendix I: MoH FVAIG).  For example,  does the policy refer to legal obligations on reporting family violence to authorities."]
[null,"3","The policies and procedures are readily available to staff on the intranet (within 3 clicks).","Review/trial of Te Whatu Ora intranet"]
[null,"4","All family violence policies and procedures have input and are endorsed by Māori leadership.","There must be documented evidence of input from Māori health leaders into family violence policy and procedures. This input may occur at the local or regional level and should be evidenced through records of relationships, meeting minutes, or email correspondence."]
[null,"5","Additional safety and security measures are specified for suspected cases of child abuse and neglect with perceived immediate risk, and for adults who are identified as high risk or in imminent threat.","A review of policies and procedures should specify protocols for responding to situations where children or adults are perceived to be at immediate risk. This may include mechanisms such as alert systems, police referral pathways, ward lockdown procedures, consideration of other children in the home, use of pseudonyms in hospital registration, social admissions, and discharge planning."]
["Collaboration","1","There is clear evidence that a Memorandum of Understanding (MOU) between Te Whatu Ora and  Oranga Tamariki and Police for child protection responses has been  operationalised by:"]
[null,"1.1","Signing of MOU.","MOU signed by each agency."]
[null,"1.2","Regular meetings at service level with actions and accountability (at least biannual).","All three agencies are represented in service level meetings. Evidenced by meeting calendar appointments, notes/minutes or agendas and example of actions taken."]
[null,"1.3","Interagency review of cases.","There must be documented evidence that all three key agencies are represented in case review processes, evident in case review agendas or meeting notes."]
[null,"1.4","Participation in or initiation of interagency training.","Contribution of Police and OT to health training on the local level qualifies. Ideally, however, there should be opportunities for interagency training that involve shared learning across sectors."]
[null,"2","There is  evidence of Service Level Agreements  (SLA) between Te Whatu Ora and family violence services with regards to referrals and how on-site services will be provided.","There must be written evidence (e.g. document, letter, email) of an SLA  with a local family violence service (e.g. Womens' Refuge, SHINE), and it should specify how on-site services will be provided.  This item is to be answered by senior VIP manager."]
[null,"3","Ongoing partnership between Te Whatu Ora and Māori service agencies or health providers, and/or local Iwi or Urban Māori Authority evidenced by:","For each agency or authority, there must be documented evidence to qualify for a 'yes'. For example, governance group email list, policy review notes/emails, training information or documentation."]
[null,"3.1","Participation in, or initiation, of training (e.g. involvement in the VIP training at Te Whatu Ora).","For each agency or authority, documented evidence of training engagement (e.g., participation in panel, providing feedback, involved with interpreting training evaluation reports) is needed to qualify for a 'yes'."]
[null,"3.2","Policy review.","For each agency or authority, Māori meaningfully engaged with policy review."]
[null,"3.3","Representation on the VIP governance group.","For each agency or authority, evidenced in governance group email list and meeting minutes."]
[null,"4","There is evidence of engagement and collaboration with external family violence services agencies at a senior management and operational VIP level."]
[null,"4.1","Senior management level (provide examples).","There must be documented evidence of collaboration and engagement between senior VIP managers and family violence agency representatives. This may include meeting minutes, agendas, or email correspondence."]
[null,"4.2","Operational VIP level (provide examples).","There must be documented evidence of an operational relationship between the VIP programme and a local family violence specialist agency. Acceptable evidence includes email correspondence (e.g., with Women's Refuge), meeting notes, or other records that demonstrate active engagement and collaboration."]
[null,"5","There is an MOU or SLA with the following agencies regarding the service delivery for victims of sexual assault (adults, adolescents and children).","Evidence of an MOU or SLA for sexual assault victims specific to delivery of health services is needed."]
[null,"5.4","Te Whatu Ora policies specify the pathway for service delivery including acute response and referral for sexual assault or suspected/alleged sexual abuse of a child.","Policies show a response and referral pathway (e.g. an emergency department flow chart). Will likely reference Sexual Abuse Assessment and Treatment Service (SAATS)."]
[null,"6","At least two multiagency case reviews (one for IPV and one for CAN) have been undertaken in the last 12 months, specifically evaluating health actions within the family violence response.","To qualify, each review must be supported by documented evidence such as: Meeting notes, Case review agendas or Output recommendations. This ensures that health sector contributions are actively assessed and that interagency collaboration is occurring in both IPV and CAN contexts."]
["Documentation","1","Standardised documentation instruments (or templates) that are aligned with the Ministry of Health FVAIG are used to record known or suspected cases of family violence.","Evidenced by an examination of the documentation instruments/forms for both IPV and CAN."]
[null,"1.1","All IPV routine enquiry, disclosures and referrals are documented on the standardised templates (e.g. Intimate Partner Violence (IPV) Assessment and Intervention Documentation).","This is evidenced by a spot chart audit of persons receiving routine enquiry and/or disclosing IPV"]
[null,"2","The national form (Report of Concern) is used for referral to Oranga Tamariki.","A review of referrals to Oranga Tamariki, made during the audit period, used the national form."]
[null,"3","Patients with injuries caused by family violence are routinely offered a medical photography option, either in Te Whatu Ora or by the police.","\"Best practice for women to have the option of injury photographs as part of their medical record (for future reference) without having to file a police report.  Evidence should be in policy, procedure and documentation template that injured patients are routinely offered the service.”"]

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