Hi, everyone, and I would like to welcome you and thank you for attending today's webinar. 2023 National Standards of Accreditation for Children's Advocacy Centers. This webinar is being brought to you through IFN's Technical Assistance Project. We are grateful to be able to host Allison McKenzie and Diana Shun for today's webinar. My name is Gail Horner, and I am one of the forensic nursing specialists with IFN. So we'll start with just a few housekeeping items. Today's webinar is possible due to funding provided through the Office on Violence Against Women, and the presenters of today's webinar disclosed no conflicts of interest. If you have multiple people watching today's webinar with you, please send a list of all attendees that have not formally registered for the webinar to safetya.forensicnurses.org, and I'll share that email address in the chat, and then share the evaluation link with them. As a benefit of membership, IFN members are eligible to receive 1.5 contact hours for this continuing education activity. The IFN is an approved provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. For IFN members to obtain CE for this activity, they are asked to attend the webinar in full and complete the post-activity webinar evaluation to obtain a certificate documenting the contact hours for this activity. For non-IFN members, with the completion of the post-activity webinar evaluation, you will receive a certificate of attendance. For all IFN members, please note that IFN is currently in the process of changing the vendor for our online learning center, so evaluations for the webinar that will provide the CE certificate will come to all attendees via email from Amy Valentine after January 2nd, once this transition is final. The webinar is being recorded today and will be available on the safetya website for viewing at a later date. IFN will send an announcement to all registered attendees once the webinar is available for viewing. With all of that housekeeping out of the way, I'd like to introduce today's presenters. Allison McKenzie is the Director of Accreditation at National Children's Alliance and manages the accreditation process for child advocacy centers throughout the country. Previously, Allison was the Senior Program Associate of Accreditation at NCA as well as Program Associate at NCA, managing grants and memberships for the southern region of the United States. She has a Master's Degree in Social Work and a Certificate in Human Service Management from Boston University. Ms. McKenzie has years of experience providing training and technical assistance at children's advocacy centers across the country. And Diana Shun is the Chief Executive Officer of the Child Advocacy Center of Sedgwich County. She serves as the voice of the CACSC and brings her passion for community development and education to wage a battle against child abuse in Sedgwich County. Diana is a graduate of Bethel College where she received her BSN. She has practiced nursing in a post-surgery floor, the emergency department, and in-depth investigations and forensic nursing. Prior to her appointment with the Child Advocacy Center, Diana served as the Director of the Sexual Assault Nurse Examiner Sexual Assault Response Team Program at Via Christi Regional Medical Center in Wichita, Kansas for 15 years. She continues to provide educational opportunities on sexual assault and forensic nursing. For over 30 years, Diana has focused her efforts on helping victims of abuse and serving as an advocate in a variety of different ways. The heart of her job entails bringing together a multidisciplinary team where the Child Advocacy Center serves as the umbrella agency for the coordination of services needed throughout a child abuse investigation. And so with that, I turn the reins over to Diana and Allison. Great, Gail. Thank you so much and thanks everyone for joining us today on the webinar and learning some more about the National Children's Alliance and our standards of accreditation specifically how they are related to medical evaluation and child physical abuse. So we will get more into that in a little while but again I just wanted to thank you for having us here with you today and you'll be hearing more from Diana and I throughout the webinar related to NCA and the standards and then also just some background on Children's Advocacy Centers in general because we're not quite sure of everyone's level of knowledge related to that. So we will get onto that a little bit further along in the slides. And another thing I just wanted to mention is if you all have a question, please feel free to put it in the chat and we're happy to kind of field anything that comes up. Chances are if you're thinking it, someone else listening to the webinar is also thinking it or someone who listens to the recording may have a similar question. So we really appreciate if you are interactive with us related to anything that might come up. And with that before we jump right into the standards, I was going to let Diana just talk a little bit about Children's Advocacy Centers and multidisciplinary teams in general so we all have some basis knowledge as to how this all plays out for kids and families. I'd be delighted. Hello, it's good to be here with you today. Thank you so very much for the opportunity. Many of you may be familiar with Child Advocacy Centers but some of you may not and so we just wanted to be able to make sure that you understood and had the opportunity to be able to know a little bit more about where we're coming from in our experience. And so working at a Child Advocacy Center really is the heart of trying to pull all the different team members together to be able to make sure that children have the adequate services that they need to be able to really start to heal and to be able to move forward in that process. So there's a variety of team members obviously that participate in regards to the multidisciplinary team. Part of the Advocacy Center's responsibility is to really make sure that coordination happens on a regular basis. And so we look at the opportunities of looking at our accreditation standards as a guideline to be able to be basically the minimum expectations of what we want to be able to make sure that we are doing as a Child Advocacy Center. And that's extremely important in guiding us through that process of really making good connections with our team. The other thing that National Children's Alliance does for us as a Child Advocacy Center is really be able to provide us with support with advocacy and quality assurance kind of information as well as just national leadership. And so we as being a Child Advocacy Center that is accredited through NCA benefit in many different ways from them. And I think it's also important just to know that there's about 950 Child Advocacy Centers across the United States. So you may have one in your own community. You may have one that's close to your community. And so we just encourage folks to really get involved with what a Child Advocacy Center can be and how that ultimately helps move forward your role as a forensic nurse and the different services that you might be able to provide in your community. Many of you are probably familiar with your multidisciplinary team members, adding law enforcement and child protection services, prosecution, mental health, medical, certainly here, the reason why we're here today, and then victim advocacy. And there can be a host of other folks that are involved in the multidisciplinary team, but those are really your primary team members. The Child Advocacy Center really provides a variety of different benefits to the community. And one of those would be just a child safe, a child friendly environment to be able to work within, really talking about access to services that need to happen to be able to really provide the support that the child needs and the family needs. The Child Advocacy Center also then the behind the scenes piece really is the ability to be able to enhance communication between partner agencies and making sure that we're working on the same page and that we're communicating well so that the child isn't the one that has to repeat the information over and over again. It's us as the professionals then that share that information in a variety of different settings and ways. But open communication is an absolutely essential piece of the success of a Child Advocacy Center. Multidisciplinary team meetings happen on a regular basis to be able to help with the communication piece and to be able to review cases to be able to really make sure that we are on track and doing what's best for children. And then certainly making sure that children have access to medical evaluations and what that might look like depending on the needs that they specifically have and the concerns. So therapy is another essential piece, making sure that either there might be onsite therapy or referrals within the community that they work with through linkage agreements. And that's an absolutely essential piece to that. And then there's just a lot of expectations that families have when they come into a Child Advocacy Center because of the stress that they're under. And we want to make sure that all of our employees are very familiar with those stressors and familiar with what families need so that we're all be able to anticipate meeting those needs in those particular situations. And then the success can also be measured in many different ways. And that success can be from tracking data. And you're familiar with data tracking, I'm sure, in your regular jobs. So ours is no different. Really looking for outcomes and outputs and making sure that what we're doing is effective and making a difference in the life of a child. A Child Advocacy Center may be a non-profit. It may be some facility that's located within another facility, such as a hospital. It could be part of the prosecutor's office. It could be under another umbrella agency. And so there's lots of different ways that Child Advocacy Centers function and look. And it may be different across just from one community to the next. There's a lot of unique different pieces to it. But there's also, as we talked about, some real strong commonalities that are provided to us by the accreditation standards that each of our communities are going to reach. But we all do them in a different way. And that's the beauty of being a Child Advocacy Center is having that uniqueness to it. Ultimately, the forensic interviews are a significant part of the Child Advocacy Center providing a child-friendly environment for that forensic interview to happen so that children can come in and really have the opportunity to disclose in a variety of different settings. So that's the background of a Child Advocacy Center and certainly encourage you to be involved with those. Great. Thank you, Diana. It's a great overview. Let's move our slides along. The National Children's Alliance, we revise our standards for accreditation every five to seven years to make sure that they are reflective of the most up-to-date best practice and research. And we recently just went through that process over 2021-2022. And our revised standards went into effect as of January 1st, 2023. All of the sites that have been up for accreditation or re-accreditation over the last almost full year, which is crazy, they've gone through under these newly revised standards for accreditation. And there were some significant changes made to some of the other standards for accreditation, but the medical evaluation standard, there was not a ton of significant change because we have noticed since the last iteration of the standards went into place in 2017 that centers are still having a challenge meeting the medical standard. And I truly think it's because in certain communities it's hard to find a provider that has the appropriate training. And we've seen that as a challenge across the country. So that's why we're so grateful to partner with IAFN and be able to share some more information with you all regarding CACs and the National Children's Alliance. And then also let you see what some of the requirements are for meeting our standards for accreditation. So while we revised the medical evaluation standard, we also added a new optional standard, which is related to physical abuse. So we'll get into that a little bit more in depth later on in our presentation, but you did these revisions using a task force of professionals from across the country. And Diana was part of our medical task force. So she was privy to all of those conversations we had regarding the requirements and what's necessary to be able to provide these exams for these kids. And so that's why she's a great partner in today's webinar with us today. With that being said, on the slide in front of you, you'll see what our definition of a medical evaluation standard is. And I'm not going to go read all of the language to you, but the language in the standards is very specific and we refer back to it when centers are having questions related to any training requirements or documentation requirements. That's why we keep it all on the slides for everyone to see. But this just states that the specialized medical evaluation and treatment services are available to all CAC clients and coordinated as part of that MDT response that Diana mentioned. And all of NCA standards are structured similarly in that the first couple of things you're going to see in the standards are the definition, and then we have a rationale for each of the standards, which really helps ground the importance of the standards. And then the first thing up is typically a training requirement. So for the medical providers that are part of an accredited CAC multidisciplinary team, they would have to meet these training requirements that we're going to go through. And I'll let Diana jump in a little bit after I go through what this first piece is. So medical evaluations are conducted by healthcare providers with specific training related to child sexual abuse. And those providers must meet at least one of the following standards. So they would be a child abuse pediatrician with sub-board eligibility or certification, or a physician without that sub-board eligibility or certification. But they would also have the 16 hours of formal didactic training. So this would be for both physicians and advanced practice nurses or physician's assistants. Just keep in mind that's like the 16 hour training requirement. And then the next piece I'm going to let Diana talk about because this is her world of work. So this is another person who could provide the medical exams for a CAC. Yeah. So the sexual assault nurse examiners will have historically gone through a 40 hour course work and then followed by their preceptorship. And the importance again with the preceptorship is that it is until the skills are, until you're competent in those skills. And so the IAFN guidelines are really married in this case to the expectations of NCA through the accreditation standards and being able to really incorporate what education IAFN expects in those circumstances. And then apply that specifically to the practice as the sexual assault nurse examiner working within the child advocacy center or correlating with the child advocacy center. And so just a couple of other things that I would say about the medical evaluation that I think are really important to keep in mind. Referrals really are not limited to those kids that we believe may have a higher likelihood of forensic significance. And so I think that's sometimes a confusing part. At least I find it often in our partner agencies where maybe law enforcement says there's not a very high likelihood that you're going to see injury because of it was digital penetration or she didn't report any pain at the time, whatever that circumstance might be. And regardless of the fact of whether there may or may not be injury present, that's not the qualifying factor as to whether we refer a child for a medical evaluation. And that's probably a practice that you're already familiar with, but I just want to reiterate how important it is that we teach and educate our team members in regards to that. Because we still, being doing this now 15 plus years here in the child advocacy center plus my 15 plus years in the hospital setting, I still hear that being used as a fairly regular maybe rationale as to why we would or wouldn't want to refer a child for a medical evaluation. Another couple things just to keep in mind that you're probably already familiar with, but the medical history really is not the same as the forensic interview. And the forensic interview is going to be a detailed, much more unique information. And the medical history is absolutely essential as a part of your medical evaluation process. That information can and should be shared with your multidisciplinary team. And sometimes you may get additional information that someone in the forensic interview may or may not have gotten. I find that to be fairly common. You have the opportunity to get children naked and they talk about their bodies more often. And that's okay and that's good. And that's part of what you share and how and why we collaborate so extensively with our multidisciplinary team. And so I think it's just really important that we are looking at that medical evaluation, not just from the episodic evaluation standpoint of what has most recently occurred in that potential touching situation, but that it's a whole health involvement. So that we're looking at their entire body and what else might have happened to them during that time. I do think that we have a kind of a unique situation in regards to that and how extremely important it is that we just recognize what additional kinds of work we can do to help educate our team members in relation to that. And again, nurses may be working onsite, they may be working offsite and either way we're collaborating through those business agreements or through our linkage agreements that we have. And it's up to the Child Advocacy Center to reach out to really have that linkage agreement signed. And sometimes it may seem, why is the CAC asking for all of this additional information? And again, that's just a part of making sure that we have our services in line so that we know when there is a referral or when we want to make a referral that we have all of our ducks in a row, so to speak to be able to make that happen. And so we do ask a lot of additional information and we do ask for a lot of documentation that may go hand in hand with that, but that's extremely important as it relates to that. I think those are the main things that I wanted to talk about, but the competency-based again, I think is fairly clearly outlined in the IAFN guidelines and just a normal part of the expectation of you reaching proficiency. That's really helpful information. And I would also say that a fair amount of the CACs across the country utilize same nurses as their medical provider, just for accessibility and things like that. I know that they're an integral part of the MDTs in many communities. Yeah, and I would also say that on the National Children's Alliance website, you can access the entire document that has all of the information about accreditation and the expectations in relation to that. And then there's another entire document that talks about putting it into practice. And I think that those are really good documents for you to be really familiar with if you're working with a child advocacy center, what those expectations are from an education standpoint, from a documentation standpoint, from a sharing of information standpoint, all of those different kinds of things. And so I would really encourage you if you're working or have an interest in working with a child advocacy center to go on the NCAA website and pull those standards off so that you have the opportunity to really review those. Great, thank you. And then moving on to our essential component B, and this just states that any of the medical professionals providing services to CAC clients, they must have a minimum of eight continuing education hours in the field of child abuse every two years. And I know that for the medical professionals that this is really an easy one to meet because the expectation of ongoing training is a little bit different for our medical professionals versus some of our other disciplines on the MDT. But definitely as you're looking at all of our standards, there's always an ongoing training requirement as well. And for any medical professionals that are also teaching in the area of child abuse, that would count towards those eight hours of ongoing training. Yeah, and I would just say your initial education is just the beginning and the ongoing education and keeping up to date on research that's being done in the field and new information that's available to you is all an extremely important part of that ongoing, keep making sure that you're up to date in what you're doing. The quality, continuous quality improvement is another expectation of the medical provider and making sure that you're really connected into whether it's American Academy of Pediatrics, APSAC, the American Professional Society of the Abuse of Children. CDC obviously is putting up new information in regards to STIs on a regular basis. So all of that would be an expectation of the ongoing education that you would want to keep up to date. And so those eight hours really should be fairly simple for you to be able to meet. But again, the CAC will need documentation of that. And so that means you share your certificates with the CAC and they keep those on hand, not just you having them in your own file. It's the training documentation. It's forever trying to keep track of all of that. Yeah, and I would say too, just from a practical approach in regards to that one, there's a lot of support services that are available to you. Your child advocacy center should be very familiar with the Midwest Regional Child Advocacy Center. They have the EdNet webinar series as well. Obviously, IFN is loaded with information. So there's a lot of ways that you can reach those continuing education credits at a fairly simple way through never even having to leave your house. I would say that, again, is just a fairly simple expectation for you to be able to meet. Yeah, and definitely technology has been very helpful in that training realm. It is the beauty, isn't it? Yes. And so our essential component C is on the screen in front of you. And it just states that medical professionals providing sexual abuse evaluations of CSE clients must demonstrate that all of the findings deemed abnormal or diagnostic are undergone expert review. And we'll talk a little bit about who can provide that expert review, but just to outline for all of you that we made one change to the medical evaluation standard. And this was the one change when our previous iteration of the standards, it said that 50% of all of the abnormal findings had to undergo expert review. And the group Diana included really felt that all the findings that were abnormal or diagnostic need to undergo this expert review. And as Diana mentioned earlier, there isn't necessarily a ton of situations that this happens. So the group didn't feel like it was gonna be a big lift going from 50% to 100% of those exams undergoing expert review, because that was really what the minimum practice should be anyway. So that was the change. And I have to say, I was a little bit worried that people in the field were gonna, this was gonna cause them some anxiety, but it's everybody's, it's been totally fine. And we've have almost a year full of the accreditation site reviews under our belt. And this has not turned out to be a challenge area, which is I think really helpful for everyone. But I was gonna let Diana talk about who can be that expert review. Yeah, so one of the things that we look at is obviously most sexual assault nurse examiner programs or forensic nursing programs have a medical director. And that medical director may or may not have a lot of significant experience in the realm of forensics. And that's fairly normal because a lot of our standing orders and those kinds of things can come from someone that is obviously experienced in sexually transmitted infections or a variety of other things. But one of the things that we look at specifically in regards to making calls on positives or concerning findings in relation to our sexual abuse evaluations, we really wanna make sure that person has the expertise that are needed to be able to really review, to really challenge us and not just say, oh, I don't know, whatever you think is okay. So that's one of the reasons why we have the who is determined to be that expert review or in this case considered to be the advanced medical consultant. And so the advanced medical consultants can come in a variety again of different opportunities. They may be housed within your CAC. They may be a direct linkage agreement that you have with someone, or it can again be provided by my case review through Midwest Regional. And then there's many other states that also have child abuse professionals or child abuse physicians, I should say CAPS, that will be doing reviews and have already set up some kind of a review process within your state. And I don't find it to be a real significant challenge for folks to be able to find someone to be able to do this review process. As long as there's communication and you're really working with it. And I think the CAC helps take that lead in regards to making sure that there is someone that you can rely on in relation to that. Again, I think the most important thing that we look at is I would want to know, and I have always wanted to know that if I'm making a call of something being abnormal or concerning, that I have somebody else that would also agree to that same finding. I don't wanna be jumping to conclusions. I don't wanna be over-calling something. I don't wanna be mis-calling something. I want to make sure that what I am documenting and how I would be able to ultimately testify would be consistent with someone who has at least my level of education, if not an experience as more than that. And that's why we then further define a little bit here who those folks are and what kind of advanced education they need to have or experience. Yeah, so this just further explains who could be considered qualified as an advanced practice person to be able to looking at those abnormal findings. It would be physicians or advanced practice nurses who also have these minimum qualifications, which are those training standards that we talked about a little bit earlier. And then having had performed at least 100 child sexual abuse exams and are current with all of their CQI requirements. Yeah, the continuous quality improvement obviously is essential for everyone and not just the RN level. That's going to be an expectation that all of the folks have. And so your folks that are gonna hit into that qualification of being the advanced medical consultant are going to be held to that same standard of the CQI work that anyone else is going to be as well. And so that review process then can be a de-identified case information. It doesn't have to be identified to the person that you're consulting with, but again, from a HIPAA standpoint, you can sign those business agreements, you can sign the, so you have with those folks and that takes care of the concern in regards to the de-identification. From a documentation standpoint, the CAC is going to need to have documentation. Again, that is completely de-identified, but that information then would just state who was the examiner? What was the date of the examination? Are they pre or post pubescent? And then what were those findings or concerns that brought that case into that 100% review? And then ultimately does the reviewer that you're collaborating with, do they agree? Is there a concern? Is there additional findings that they saw or they feel like you may have over-called something, whatever that outcome is. And there is again, in the standards, an example of that kind of a form that can be used to keep that information tracked so that that goes back to the CAC. And the CAC again, has to be able to show that as a part of our accreditation requirements. So sometimes again, I think the healthcare providers are like, I'm already keeping that. Why do I need to show it to you? That's a part of our expectation as well to be able to meet our standards. Sometimes there does seem to be like this duplication of documentation, but it is essential and it is an important piece for us to be able to show that we are indeed making sure that those cases are being reviewed before they ever would go to court or whatever circumstances that might bring. Thank you. And then now for the rest of the standard, it's probably gonna be a little bit more focused on protocols or linkage agreements, things like that. Because what we do through the accreditation process is we make sure that everything that's in practice is also reflected in policy or procedure so that those two things are in alignment because we found that when they're not, that's when there are some challenges that come up for the kids and families that are being served at CAC. So this essential component just outlines that specialized medical evaluations for child clients are available onsite or through linkage agreements with appropriate institutions, agencies, or providers. Yeah, and I would say, again, that can happen whether that's onsite and on the CAC or at the hospital or a clinic or an emergency department, but we're making sure that our, as the CAC, that our linkage agreements are then also following those expectations of the minimum educations of the sane education that we talked about earlier and or the physician and the nurse practitioner or the child abuse pediatrician. So we're gonna still go back to those expectations of education as we are looking to who we are signing our linkage agreements with. And then that the institution themselves, maybe you have two sanes that are on staff in your emergency department and the night that a case comes in, neither of them are working or neither of them are gonna be able to be reached when they're on call, then it isn't, it's the expectation then as we sign that the hospital is gonna make sure that someone that meets that expectation is going to be the person caring for that child. Then you as a hospital are taking on the responsibility of saying, yeah, we have backup. We have an alternate way then that we can make sure that we are meeting that expectation or we're bringing the child back for an evaluation at a later time, if that's a possibility. Again, it depends on the circumstances, but so it's a two-way agreement that yes, we're saying these are the expectations and then the healthcare provider saying, yes, this is what we're agreeing to do. And then this next requirement just outlines that the evaluations are available and accessible regardless of ability to pay. And I think this can sometimes be concerning, particularly for the Child Advocacy Center, at least in my opinion, as I do the fundraising for it, but we're gonna just make sure that there's access and access can mean again, that maybe they have insurance and they're able to pay their co-pay. Maybe they have insurance, but they're not able to pay their co-pay. So that's a reason. We don't ever want a cost to be a reason why they say, we can't go through that medical evaluation. We don't have the money to be able to pay for it. So crime victims' compensation is usually available in many states. And so that's going to be another responsibility that the CAC will help take on is to be able to make sure and get folks connected into that. But ultimately ability to pay should never be the reason or the rationale as to why a medical evaluation is or isn't done. So the CAC will help assist in trying to problem solve that. I know many hospitals will write off those expenses. So again, it just depends on your community and how that particularly looks. And then this essential component F, it states that the CAC and MDT written protocols and guidelines include access to appropriate medical evaluation and treatment for all CAC clients. Yeah, I think the challenge with this one, many, as we move into the next component of the physical abuse, the next standard of physical abuse, sometimes that's a little overwhelming because we think about do we, are we as a healthcare facility, are we responsible to be able to make sure that we're meeting all of those guidelines? And ultimately what we want is children taken care of by people who are trained to be able to recognize child abuse. And in this case in particular of this standard, sexual abuse. And if again, we as a healthcare institution do not necessarily have the people trained to be able to do that, are we able to access that support? And so whether, again, that's something that we help with linkage agreements, we move them to another community, which isn't always ideal, but sometimes necessary in some rural areas. Are you making yourself as a SADM program available to surrounding communities so that they're able to refer clients into you if you're the only program within that area? And so we just really want folks to be able to make sure and talk about that you have steps in place if you are in a healthcare facility that does not provide that level of expertise that where you can reach out to be able to get that support that you need to be able to provide those services. Yeah. And that again is when we're gonna look at what's happening in practice and then what is reflected in policy or protocols, guidelines, I know people use different words, but yeah, that's what we'll be looking for, accreditation purposes. And then we have essential component G, which again is related to protocols and guidelines and that those include the circumstances under which a medical evaluation for child sexual abuse is gonna be recommended, provided and accessed. So this really is just to make sure that everyone who's part of that multidisciplinary team understands when a medical evaluation is gonna be recommended and how that's all gonna happen. And I know as Diana mentioned, it looks a little bit different depending on the community and the resources available, but for accreditation purposes, we're gonna need to know how that happens for each CAC. Yeah. So some of the things that we look at particularly, obviously the primary goals of that medical evaluation should be ensuring the health, safety and wellbeing of the child and to be able to provide the evaluation, the documentation, the diagnosis and really being able to address any medical conditions from that potential concern for abuse. We also want to make sure the medical provider is differentiating between findings that are abusive in nature and findings that are related to other medical conditions so that we're ruling out other potential causes or findings, be able to do the documentation and the diagnosis, addressing the medical conditions then that are unrelated to abuse. Really looking from a developmental standpoint, what is this particular case related to the developmental expectations of this child and where they are in their age group? What are emotional and behavioral issues that might be related to that and things that need further evaluation, referrals or treatment. Is that another part of the medical evaluation? And then being able to really educate the family and the supportive members that are there with them about expectations of the examination and outcomes in relation to that, providing those next steps of reassurance and letting them know from a healthcare perspective what follow-up they might need or that they are indeed healthy. That's the most common evaluation that we will probably be doing in many of these cases, ensuring the child that they are normal and that they are healthy and that they're able to grow and be, quote, normal in relation to that. And then making recommendations for mental health referrals if that's not something that's already previously been done. A lot of it, again, may depend on whether that child is presenting to the hospital first or if they're coming to the CAC first for their forensic interview and then being referred to the medical component. A lot of that, again, is just good communication between them. And that requires good written protocols to be able to identify the how, when, and where the examinations are going to happen. What are the timeframes? So really being able to set out those components of what's considered to be an emergent evaluation that needs to happen right now or without delay. What are those that are urgent in nature, but they're not necessarily something that has to be happening right now, but could be scheduled. Those that are non-urgent, excuse me, non-urgent in nature. And then those that might just require additional follow-up or additional referrals. We know that these cases may come into the healthcare provision and there may be disclosures of abuse. There might be witnesses. All of that is so extremely important that we're making sure and just really having good communication with our partner agencies. And again, there's more additional information in that putting things into practice. A standard on the NCA website that I would encourage, again, just be very helpful for you to look at. And then we have essential component H, which talks about the documentation of medical findings being maintained by written record and photo documentation and that the record storage must be HIPAA compliant and medical record storage must be secured, sufficiently backed up and accessible to authorized personnel in accordance with all applicable federal and state laws. And we recognize that things can be a little bit different from state to state. So we just wanted to be cognizant of that as we were updating some of the language in this requirement. This was a requirement in the previous iteration of the standards. We just further clarify it during this last revision. And I think anytime you're releasing photo documentation there should be good documentation of who you are releasing that information to and the reason why, basically. Is it part of the investigation? Is it law enforcement? Is it related to another physician who's going to be doing your review? Whatever that might be, but I think that it's important for us to just make sure that from a healthcare perspective that we're covered when we are releasing that HIPAA information that that is a piece of our documentation that we're keeping of who and where has access to that confidential information. And then we have our essential component I, and that is outlining that team members and CAC staff are trained regarding the purpose and nature of the medical evaluation for suspected sexual abuse and that there is a designated team member or staff to educate children and caregivers regarding the medical evaluation, including what it is and what it is not. And I feel like this piece is really important to ensure that all of those multidisciplinary team members know enough about what the medical exam is and is not to help relay that information and educate the children and caregivers. So I'll let Diana talk a little bit more about that since you've had to interact with those team members. Yeah, again, I think that the education piece is an extremely important piece so that team members know what the medical evaluation is, why you're doing the evaluation, how they access you, the communication that you're going to be able to have back with them. They should also be able to talk to team members about, excuse me, talk to the child and to the non-offending caregivers about what that evaluation looks like in just kind of general terms so that they can decrease anxiety, but also really encourage for that child to have the evaluation completed. A lot of that goes back to really just making sure that your MDT members are well-educated so that they feel more comfortable in what to expect in regards to that. Yeah, and this- Diana. Oh, excuse me. Yes. There's a question in the chat. Oh, good. Sorry. Go ahead. I haven't been monitoring that. I'm glad you are. Please discuss the same key role in helping determine if the case should be moved forward. I've only read this in the putting standards into practice. Okay, so say that again. Please discuss the same key role Please discuss the same key role in helping determine if the case should be moved forward. Okay, forward, just to ask some clarification, are you talking about forward as far as for charging or forward in the investigation? I just want to make sure I understand it correctly. Deborah, if you want to type something to clarify. Yeah, I'm guessing it's probably related to the investigation. So maybe- Yeah, I would say- Reverting any abnormal findings. Got it. I see it now. Yeah, so the same key would be the one then that would be saying to, within their own practice, you will have something already set up. If you have concerns for a finding, you say that you do have abuse of some healed trauma present, those kinds of things or acute trauma, then it would be your responsibility as the same key to make sure that you have that person who is going to fall into that approved person to be able to do the review that you're moving it forward for that review process. So the CAC is relying on the healthcare provider to have those expectations or to have those linkage agreements already in place for whom they can go to then to have that review to be able to meet the 100%. Thank you for your question, Deborah. Okay. He's saying yes. Thank you. Okay. Thank you for asking. Yeah. And that is something that's come up lately that a lot of CAC directors aren't necessarily medical professionals. So that's why the medical role on the multidisciplinary team is so important. And you really are that expert. So the center directors are going to be relying on you to be able to make sure that all things are functioning the way they should in terms of that expert review piece. And see, hopefully it's going to be doing a little more training for executive directors on that so that they can feel a little more confident in their knowledge related to how that process is all playing out. Great question. And then this last essential component just outlines that those findings of the medical evaluations are shared with the team in a routine, timely, and meaningful manner. Depending on what the findings are, I think probably change that time frame. That can be verbally, it can be written, it just depends on what the urgency in regards to that is, but ultimately you don't want, let's say you have a healed trauma, a healed hymenal tear that you've identified. You wanna make sure and communicate that in a timely manner, because that's something that the investigation will want to know and be able to further explore in relation to their investigation side of it as well. Or maybe you've charted something that you felt was trauma and they're moving forward with charging based off of that interpretation. Then it's important, again, that's a quick phone call and you say, no, I've had that case reviewed and indeed that happens to be in sclerosis and it's not acute genital trauma. Whatever that level of communication needs to happen, it just needs to happen based off, you know, in a timely manner. Again, not everything has to be emergent, but there are times where it does need to be emergent. And then just having that opportunity to be able to share those findings on a regular basis is really important. And I think, again, for these that have a child that have a forensic nurse located within their CAC, they have that beauty of being able to run down and say, hey, tell me what this finding means or what does this look like or how does this change our investigation? But the same thing can happen by picking up the phone, even if you're not co-located together. A lot of it, again, goes back to you developing relationships in your community with your folks to be able to really encourage them to know that you've got an open door and that you want them to ask questions if you have specific concerns. Because the medical findings, particularly in those cases where there are positive medical findings, can really push forward some of that investigation process and the potential for it being charged in many of those circumstances. I would also just say, remember, again, that you have a mandatory reporting requirement so that if the child does tell you something that maybe they didn't tell someone else, you're wanting to make sure and communicate that information. And that you always have the HIPAA release to be able to talk to your multidisciplinary team partners in regards to this. HIPAA takes the second seat when there's an active open investigation. And so sometimes that's confusing with the hospitals. Sometimes that's not a real comfortable thing. But again, you want to make sure that you get your hospital lawyers involved in this discussion so that they understand as well that there is that capability for you to release that information and an obligation to do so. Just looking at the medical evaluation standard as a whole, we have about 125 to 150 centers that go through accreditation every year. So we track all of that data very closely. And some of the frequent challenges and trends are being able to demonstrate that the medical provider has the required foundational training, which I know we talked about earlier in our webinar. And then having medical representation regularly participating in MDT case review. And this, I feel like the second bullet is definitely a bit more of a challenge for centers than the first one, especially if there is one medical provider that is serving multiple CACs in multiple counties. It's really hard to try to figure out how to also attend those case reviews, but it is so important to have that medical voice at the case review table, making decisions about specific cases, but also just talking about children in general and what's developmentally appropriate and all those other things. Diane, I'll let you weigh in on that. I would say too that if you are real challenged and stretched in trying to cover multi-communities in particular, even in our community where we're only one, we only have one MDT that they need to attend, but we do offer now, I guess a good thing out of COVID, we now offer that opportunity to be able to Zoom into our meetings. And so it's a little easier than driving from one facility to the next, but then to be able to just connect in through some kind of a platform like Zoom to be able to participate in those meetings. So I would really encourage you to talk to the CAC and see if that's a capability that they can also incorporate if you are having difficulty meeting that expectation. Yes, the technology does help you not having to go in traffic, getting to another place. Yeah. And then just to highlight, we've had probably 700 centers go through the medical evaluation standard under the 2017 requirements. And you'll see the one essential component that has been most challenging for centers if they're not meeting the medical evaluation standard is that expert review piece. But if you think about it's 27 centers not meeting that, but having had 700 plus go through the standard that we're still doing pretty well. I think that technology piece with the my case review, if a center is really struggling to find some other sort of expert review does definitely help when those are some challenging situations. And I think overall, I found that child abuse pediatricians, no matter what state they're in, are very interested in helping you in your state figure out other options as well. So they are well-connected individuals. Find the child abuse pediatrician in your state or in another state near you that might be able to help assist you if you do have those challenges as well. And then just the changes to the essential components, we had talked about this earlier, but moving from that 50% of abnormal findings, having that expert review to 100%, that was the biggest change for this standard, but people have been faring well so far. So that's good news for sure. And then what would that documentation look like? I know we talked about this a little bit earlier, but the foundational training documentation, as well as that ongoing training piece, and then being able to demonstrate that the diagnostic exams are reviewed by that advanced medical consultant. And Diana had mentioned the log. We've been seeing letters certifying that as well. We can be a little flexible with documentation, but we do need some sort of documentation because just to verify that how things, what's happening in practice is also what everyone's agreed upon. And then a linkage agreement, if that's how things are structured in your community with a medical provider that's not employed by the CAC. And then this is a question we get frequently from multidisciplinary team members, such as the medical provider. If you're working with an accredited CAC and they're going through that reaccreditation process, team members wanna know what the site reviewers are gonna ask them. They would ask things like, how is it determined when a child receives a medical exam or when a child receives a medical exam? Or do you regularly participate in case review? Again, that's a big one. And what advanced medical consultant do you use for your diagnostic exams? And based on those answers, site reviewers might have additional questions, but these are just some of those standard questions that they kick off with. And Diana's been on that receiving end of those questions before. Yeah, I think that they, my experience would be that for those of you that have gone through joint commission versus those of you that have gone through NCA accreditation, it's night and day, literally, because joint commission is very, I feel much more like the gotcha. How can we get you in trouble? What can we find as your failures where NCA wants to see you as a CAC succeed and they want your partner agencies to also succeed. Very different expectation and very different feel from an accreditation kinds of a process. Yes, be aware, be alert to those kinds of things, but no, this is not like an awful, terrible experience. So. That was helpful to hear. Yeah. And then just some promising data is that 93% of all the centers that have gone through the accreditation reaccreditation process over the last five or so years have passed the medical standard. So it's always good to hear. And then definitely feel free to ask questions. I know that we're monitoring the Q and A box and we will share out that some of the NCA resources that we've discussed on this call with IAFN so that they can provide links and stuff to you all as well. And then now we're gonna talk about our new optional physical abuse standard. And the reason NCA's board decided to develop, we actually developed three new optional standards. So it's physical abuse, child abuse prevention, and CSEC standards. So centers that are going through accreditation can opt in to one or more of these optional standards, but once they opt in, if they're not meeting it, then they still could wind up in the pending process, which is the same as if you aren't meeting one of the 10 required standards for accreditation. But we do a census of all of our centers every two years. And it was clear that many of the CECs now have ventured out of just solely doing the sexual abuse work to also doing physical abuse work and some neglect as well. So we just wanted to be reflective of what that practice looks like. And so with that, we developed the physical abuse standard. And I must say that updating an existing standard looks a lot different than developing an entirely new standard. So that was a learning experience. I'm glad Diana was on that learning journey with us. We had a group of about 18 medical professionals that helped go through this and develop the physical abuse standard. We've actually had three centers so far opt in to the physical abuse standard and pass that for accreditation purposes. And we're gonna have a couple of more at our January board meeting, which is really exciting. And we'll go ahead and get into this a little further. Again, the standards are all structured very similarly. So you'll notice a lot of commonality from the structure of the medical evaluation standard. And so the first couple of things that we're gonna talk about are gonna take a little bit longer, but then the rest of the requirements do definitely mirror what's in that medical evaluation standard. So we'll move through that a little bit more quickly and I'm being mindful of the time as well, because I'm sure you all have other things to do after this webinar. So we'll go ahead and get started. And again, like all of our standards, there is a definition. The physical abuse standard states that specialized care evaluation and treatment services are available to all physical abuse clients and are coordinated as part of the MDT response. And when we were having the discussions related to the physical abuse standard, it was clear that those cases probably are gonna come to a CAC in a different manner than the sexual abuse cases. So we tend to keep that in mind as we were developing the language for this standard. So just know that there was a lot of conversation related to the development of this. And Diana, I don't know if you wanna weigh in at all on that. No, I think we'll cover some of it as we move through. Awesome. So we have our rationale and I'm definitely not gonna go read all that to you. You'll be able to find that in the documents that we're gonna share with IAFN after today's webinar. Yeah, I think the main thing is just really recognizing that it's the suspected victims of child physical abuse and that it's all of them, that we have a plan in how we're going to take care of them. And then that evaluation really helping to serve as our documentation and to be able to determine causes of injury and then really plan and diagnose and treat in relation to that. And this was a lengthy rationale. Again, we were swimming in new water here, so I wanted to make sure we were encapsulating all of the things that needed to be included. Yeah, so I think, again, the take-homes and as we looked at the rationale is really the importance of follow-up and then sharing that information and really making sure the history, the medical history is a part of that document, which again would be a normal process. But it's physical abuse cases in and of themselves have a lot more dynamics and uniquenesses to them than many of our sexual abuse evaluations. And so I think that guides or gives maybe some additional information as to why and whom is considered to be capable of some of the different components in relation to the physical abuse evaluation. Making sure, again, that the policies that each of the CACs have and their healthcare providers that are uniquely different for the physical abuse case, then some of them obviously are correlated, Alison was mentioning, but there are some unique differences just for the physical abuse cases. Yeah. For essential component A, it states that the medical exams and documentation are conducted by healthcare providers with specific child physical abuse training meeting at least one of the following training standards. So that would be a CAP or someone who's eligible to be a CAP or physicians without that Child Abuse Pediatric Board Certification eligibility, but who have advanced training in the field of child abuse and have practiced in that field for five years and or at least 50% of their cases are child physical abuse cases. And there was a lot of discussion about what this requirement would be and also trying to keeping the group reminded that these are minimum standards. It was just a lot of interesting conversation related to this. Oh, sorry. Go ahead. The second star there really then is deemed because you'll see them later in the standards that talks about or individuals who are acting as a CAP. And that's that phrase there. So in their community, they're acting as a CAP, even though they don't have the CAP designation from a certification standpoint. Yeah. And when we were having this discussion with the sexual abuse training, there were clear cut trainings that would meet those requirements. And with this training, it seemed like there was a lot of varying training. So there wasn't one specific one that could check a box, so to speak. And so that was just an interesting takeaway from our discussions. And then, so also it would be physicians without the board certification, advanced practice nurses or physician's assistant, but they must collaborate with a child abuse pediatrician or that acting as a child abuse pediatrician, as Diana said. And then forensic nurses without advanced practitioner training would have a minimum of 40 hours of training specific to medical evaluation of physical abuse. Yeah. So your traditional SANE training does certainly have elements in relation to that, but you want to make sure then that you have the additional specific to the physical abuse. And then essential component B is in reference to the medical assessments are conducted by health care providers with specific child physical abuse training, meaning at least one of the following qualifications. So you'll see on the slide in front of you, it is the child abuse pediatricians that are board certified or eligible to be certified or physicians without that certification or eligibility, but have that five years and, or at least 50% of their cases acting as a CAP. And then physicians without that certification or eligibility, advanced practice nurses and physician's assistants, but they must be connected with a CAP or a medical professional that's acting as a CAP. So this is for that assessment piece. Yeah. So the assessment piece carries along with it, the expectation that person will have the ability to order x-ray, order lab, those kinds of things, and may not be able to do that independently. And thus the rationale by the group was that would be why the RN level wouldn't fall into that category alone. History and physical exam obviously are taking into account as part of the child's injuries that might be present. And that certainly can be done by the RN level, but it's again, referring it to the diagnosis of child physical abuse versus the nursing diagnosis of injury identification that really falls into the interpretation piece of this. Is an RN level capable of doing this assessments piece independently and ultimately working with your child abuse pediatrician or someone who qualifies in relation to that is where the discussion was. That's really where the responsibility has to lie in collaboration with that. And then ultimately the continuous quality improvement piece will always come into play in relation to that and providing documentation of that CQI is an important expectation. Again, no matter who it is, it's working with these children. Yeah. So there's that, the ongoing training requirement, but again, we haven't found that to be a challenge for medical professionals, since you all have so many other requirements related to that. So that piece hasn't been super challenging. It does also identify that not only can you take the online local or statewide kinds of classes, but you can also participate in the child abuse lists serves by the different organizations. And those are listed specifically in the standards as well. I don't, I have never participated in the helper society. I think you actually have to have that CAP designation and, or other qualifications to be able to apply to that. So that may not be an option for many of the nurses at the RN level to be able to qualify to be a part of that child abuse lists serve same with the AAP, American Academy of Pediatrics. Some of the things in the standards do very specifically apply to the physician level and or the nurse practitioner level and CAP level. And thankfully there's IAFN, which is a great resource too, for these ongoing requirements. And then essential component D states that medical professionals providing physical abuse services to CAC clients must demonstrate peer review of CAC physical abuse exams. And these medical professionals must demonstrate participation in an expert peer review process, a minimum of six times per year. And then it defines on this slide for you who those expert peer review consultants would be. And this also created a lot of discussion with the group to come up with this requirement. As I said, creating a new standard is, so it looks a little different than updating and existing. Yeah. They felt like the minimum of six times per year was really important just based on the nature of the work. And so far the centers that have opted into this have been able to demonstrate meeting that. Yeah. I think accuracy is the main reason, obviously, for any time that we do this kind of a peer review expectation and you want to make sure that it's one of the best ways to be able to avoid false positives or false negatives in the diagnosis process. Accuracy is absolutely essential. Yes, for sure. And then we have essential component E and this outlines that the physical abuse evaluations are available to clients onsite or through an agreed upon referral process. And this agreed upon process may be formally outlined in a protocol or a linkage agreement or through informal agreements and also must include a process to ensure the medical needs are being met. And the outlining this informal agreement being acceptable as well was really important to the group because this is a new territory for everyone's just wanting to be mindful that some areas of the country might have more of an informal agreement process, but this is also happening. So we wanted to be mindful and acknowledge that could also minimally meet the standard. Yeah. And I think, again, it's the CSC's responsibility to make sure that the child has access to those appropriate evaluations and that who we are referring to is going to meet those expectations of being able to provide the comprehensive head to toe. There's additional kind of inspection of any other additional kinds of injuries that might be there, any neurologic implications that might be present, et cetera. And so all of that has to be identified in those policies and procedures to be able to make sure that we're meeting that. And again, that can look different in each community, whether it's onsite or through linkage agreements. But again, the CAC is going to be heavily involved in deeming where those cases are being referred to, to be able to make sure they're meeting that expectation. Yeah. And as we get further into this standard a year or two from now, we'll have more data to be able to see how this is playing out in various areas of the country. So this is still very much in its beginning stages, but exciting that centers are opting in and providing this work. Yeah. And then essential component F talks about the written protocols and guidelines include access to appropriate physical abuse, medical evaluations, and treatment. And centers must have the ability to access and provide the evaluations for children who present at the CAC with suspected minor physical abuse and the ability to refer for more experienced medical providers for those more serious cases. Yeah. So screening criteria is going to be a big important piece to that and recognizing where your appropriate referrals are going to be made. Costs become a little bit more challenging in a lot of these cases because there is so much more expense related to full body x-rays or MRIs or additional kinds of tests that need to be done. Ability to pay shouldn't be, again, a reason why a child is or isn't referred, obviously, but the hospital will have to work much more closely with the patients in these circumstances to be able to determine how payment may or may not be able to happen in relation to that. Yeah, definitely. And essential component G talks about those written protocols and guidelines include the circumstances of when a medical evaluation for child physical abuse is recommended and that medical evaluation needs to be completed by an appropriately trained provider. Yeah. So again, just recognizing the emergent versus the urgent and those exams that can be scheduled at a later time, who's going to screen, how are the screening going to happen, but any potential physical abuse case needs to have a screening criteria available so that you're following those consistently, making the appropriate referrals to that qualified medical facility, and then how is the information sharing going to happen, what the expectations are with that, and then certainly always keeping confidentiality as an important piece to that, but knowing what those parameters might look like. Yeah. And then essential component H mirrors the documentation when outlined in the medical evaluation standard as well. Just the documentation, how it's recorded, maintained, HIPAA compliant, secure, backed up, and all of this, but things in accordance with all federal and state laws. One of the things I should have mentioned in the earlier standard too, but it certainly applies to both, is that the quality of photographic evidence needs to make sure that it's meeting the expectations because whether that's going to be used later in court, whether it's going to be used by another medical professional to review that case, to determine your documentation accuracy, those kinds of things, but the photographic evidence is absolutely important to be able to make sure that it is of quality to be able to effectively have that review process and, or have it a piece of that evaluation and investigation process. Just another piece to keep in mind that if you have photographs, your Polaroid probably needs to be replaced. Finding the right kind of equipment is an extremely important part of taking on these kinds of evaluations. For sure. And essential component I states that the team members and staff are trained regarding the purpose and nature of the physical abuse evaluations. And there's designated team members or CAC staff that are able to educate clients and caregivers regarding that physical abuse medical evaluation. Yes. Again, educating your MDT members so that they feel comfortable giving a general expectation of what the evaluation should be. I still hear, oh my gosh, I would never put my child through an evaluation. So why would I refer? We need to make sure that we're squashing those false expectations of what an evaluation is and why it is so important that children are being referred. So really finding your champions within your partner agencies and making sure that the CAC is educated to be able to give good information and expectations of what that evaluation might look like. Yeah. And then again, that the medical evaluations are shared with the team members in a routine, timely and meaningful manner. And depending on the outcomes, that timeliness could be bumped up or less, but it's important that there's that ability to get the information where it needs to be dependent on what it is. And then some frequently asked questions are, what are the training requirements for the medical professionals handling these cases? And as we mentioned earlier, it could be a wide variety of training topics that are covered because we're talking about the entire body. I know there was a lot of discussion about how there isn't just one specific, go to this week-long training and you're going to meet the requirements. It's going to look a little bit different for this standard, which I think is okay because it seems to be in an evolution stage right now. But I don't know, Diane, if you want to weigh in on that. There's also a question, if I can interrupt for just a sec, sorry. Absolutely. Here's the question. We've been interested in adding physical abuse evals into our CAC, but the logistics seem difficult. We are located within a hospital, however, have only two pediatric providers. How would the referral process work from an ER? Parents slash law enforcement slash social work would be expected to bring the child the following day if seen in the ER at night. Do other centers provide 24-hour coverage for physical abuse exams? Would appreciate guidance on the day-to-day logistics. Yeah, I can take a beginning of it, Allison, and then you hop in. Most centers that are going to be reviewing or evaluating children for physical abuse will have someone that is available 24 hours a day to, at least at the minimum, answer questions that the ER may have to be able to get that child either admitted to the hospital and or then have further evaluation by the pediatric providers later or to be able to come in and see that child if it has to happen right then or just to be able to make sure that the tests and the evaluation that they are doing at that time is meeting that expectation. I would be glad to connect your hospital to our physicians that are here that have an active, it's called a care team, child abuse, and now I'm going to forget what the R and the E stand for, but they have been doing this now for numerous years. There's three pediatric providers that share call in our community and so they've worked out a system and basically criteria for when the CAP needs to be called and when they will come in versus when they'll come into the hospital and see them the next day, etc. If that would be of any assistance to you, I would be glad to help make those connections for your facility. Yeah, and as I mentioned, we have this handful of centers that have met this standard successfully. I think that those centers would be totally willing to share also how they have their systems set up. Again, it seems like a very sharing kind of situation trying to figure out this new world of work, so that's a great question. And Diana, I'll connect you too. Oh, okay, and I did just respond with my email address too. Oh, okay, she has your email then. Okay, great. Yeah, and just we have some of what would the documentation look like similar to what we talked about earlier with the medical evaluation. You'd need that training documentation and a peer review type of log or confirmation of attendance with the peer review. And then what the site reviewers would ask would be, how are those child physical abuse cases handled at your center? And that has brought us to the conclusion, but I wanted to put this up so that you have all of the contact information. And we have a couple minutes if you all have more questions or anything you'd like to talk about. And big thanks to Gail and Annette for helping us get this all facilitated and coordinated. We're so glad to be able to share some information with you all today. Yes, thank you for the opportunity and thanks for all the work that you do, so keep up the great work. Thank you, Allison and Diana. Could you advance the screen or the PowerPoint? Are you guys off the PowerPoint now? Because I don't see the PowerPoint. Yeah, I just, I turned it up. Okay. That's okay. I just want to share that again, today's webinar is being supported through IFN's Technical Assistance Grant. Through that grant, IFN has the SafeTA website that houses various educational opportunities, resources, and national guiding documents. You can contact IFN with your request for technical assistance, oh thanks, Annette, by directly calling the TA line at 1-877-879-7278 or by submitting a request form by clicking the request TA button on the website. The next, I just want to let you know about upcoming SafeTA webinar, the final one for 2023. It will be December 20th at, I don't know the time, but it'll be on December 20th. Representation from the National Children's Alliance will thankfully be with us again, covering strategies for working with children and youth with problematic sexual behaviors. We hope that you're all able to join that webinar. And then if you could advance, and again, just to say thanks again, Allison and Diana, that was really a very interesting webinar. And thank all of you guys for joining us today. Please remember to complete the webinar post-evaluation. You will receive an email shortly after January 2nd regarding the evaluation for this webinar. We're looking forward to connecting with you all in the near future, and we hope you have a great day. If you have any questions about the evaluation link or any kind of technical questions, getting your certificate, just shoot me an email. I have dropped it in the chat, but thanks for joining us today.

2023 National Standards of Accreditation

Children's Advocacy Centers

medical evaluations

abuse

training requirements

written protocols

ongoing education

Physical Abuse Standard

specialized care

collaboration

medical findings

HIPAA-compliant