The Domestic Violence Fatality Review: Can It Mobilize Community-Level Change?

Abstract

Domestic Violence Fatality Review (DVFR) teams are a means of identifying systems’ gaps in the coordinated response to domestic violence. While the number of homicide reviews has grown, little is known about whether DVFRs facilitate change in the community-level response to domestic violence. This research evaluated whether the recommendations made by one state-level DVFR had an effect on community and organizational priorities and practices. The results indicate that the recommendations influence countywide priorities, but less was done to implement the recommendations. DVFRs have the capacity to influence community-level change agendas; however, organizations need support moving from issue prioritization to implementation.

Despite increased understanding of the risks for intimate partner violence (IPV), approximately 25% of women and 14% of men in the United States will report being physically assaulted by an intimate partner at some point in their lives, (Black et al., 2011) and 1,800 women in the United States were killed by a current or former intimate partner in 2010 (Violence Policy Center, 2012). One strategy to prevent these deaths is to investigate the circumstances surrounding an intimate partner homicide to identify community-level changes that could be made to improve victim safety. Community-level or “exo-system” changes can be seen as those directly targeting the “immediate settings” and social institutions that victims and perpetrators of IPV navigate (Heise, 1998) including the criminal justice system, work places, emergency shelters, and college campuses. Since the mid-1990s, Domestic Violence Fatality Reviews (DVFRs) were developed to conduct in-depth evaluations of intimate partner homicide to identify community-level changes that could benefit victims of violence. As of 2012, approximately 150 to 175 review processes take place in 45 states across the United States (Websdale, 2012), indicating the growing frequency of these teams in jurisdictions nationally. Densely populated states such as California and Florida have as many as 20 teams running concurrently, whereas less populated states such as Montana and Kansas may have only one team conducting reviews (Websdale, 2012). It is not clear whether there is a correlation between DV-related homicide rates in a state or jurisdiction and the presence of DVFR teams. A typical DVFR will involve representatives from law enforcement, criminal justice, social service, domestic violence advocacy programs, and members of the victim's family and social networks. DVFRs vary considerably state by state, as there exists no uniform prescription for their structure or usage (Watt, 2008; Websdale, 2012).

Reports created by DVFRs are intended to assist domestic violence advocates, law enforcement, criminal justice, and social service providers in prioritizing issues for change that may improve the coordinated response to domestic violence. Despite the growing occurrence of DVFRs, limited evaluation has yet been conducted to assess the effectiveness of this process in initiating systems level change. The purpose of the research presented here is to evaluate whether the recommendations identified by the DVFR process were prioritized and implemented in counties where a DVFR review process occurred in one state.

To situate this study, in the following section we evaluate the small body of literature currently available on DVFRs and draw from the literature on issue prioritization, agenda setting, and the implementation of voluntary recommendations in other policy domains to assess how DVFR recommendations might be implemented at the organizational and community levels.

Background

DVFRs

Early versions of DVFR teams emerged in the 1990s as a process of investigating high profile intimate partner homicides. The Charan Investigation, for example, was conducted by the Commission on the Status of Women in San Francisco in 1990. This study of one woman's homicide revealed that community level improvements were needed to foster greater system-wide accountability and identify gaps in the coordinated community response that contribute to the perpetuation of IPV (Websdale, Sheeran, & Johnson, 2003). This emphasis on highlighting system-wide areas of change, rather than just individual-level factors, can be seen in the community-level recommendations issued by contemporary DVFR teams.

The fatality review process is a means of encouraging accurate data collection about DV-related deaths, increasing community-wide multidisciplinary collaboration between unlikely partners, highlighting gaps in the coordinated response to domestic violence and raising awareness about the lethal potential of domestic violence (Websdale et al., 2003; Wilson & Websdale, 2006). Ecological or multilevel approaches to violence prevention suggest that transformations at the community level challenge social environments that are permissive to violence, and ultimately lead to a reduction in the overall perpetration of violence against women (Casey & Lindhorst, 2009; Heise, 1998). Community-level interventions, such as the DVFR, hold the promise of remedying systems failures that can perpetuate incidents of domestic violence, including those that end in homicide.

Although the goal of DVFRs is system-wide change, few efforts have been made to evaluate whether communities are implementing reforms as suggested by the reviews. To date, only one article reports on an evaluation of the effect of a DVFR through a case study approach. Wilson and Websdale (2006) compiled a list of six examples of system-wide changes that were initiated in different areas of the country in response to a DVFR. Examples they cited included a county in California which established a centralized, countywide reporting system for domestic violence, and a state which now requires all law enforcement personnel to report incidences of child exposure to domestic violence homicide to the state's human services department for evaluation. While Wilson and Websdale (2006) conclude that DVFRs are “changing the contour of domestic violence services,” (p. 541) these accounts were provided by a single person in the agency charged with coordinating the review, rather than reflecting broader community perceptions on the effects of the DVFR. Limited information is available as to whether the reforms noted by these leaders have been implemented at the level of frontline workers who would be in a position to see the realization of these reforms.

Policy Implementation Issues

Although the literature on the implementation of traditional legislative policy mandates is substantial, there has been limited examination on the successful implementation of voluntary reforms such as those generated by DVFRs. Voluntary policies are agreements that go beyond what is currently legislated and are often developed by coalitions of public and private interests to influence change (Baranzini & Thalmann, 2004). Unlike legislative policies that frequently contain incentives or penalties to promote implementation, voluntary policy reforms rely on persuasion and community prioritization to implement the desired policy response. Some proponents of voluntary policies assert they have the potential of “transcending traditional implementation problems,” (Wright, 2000, p. 93) because of their greater ability to allow organizations and institutions the flexibility to adapt policies to fit their unique organizational needs or what Wright termed “adaptive implementation.”

Implementation theorists have noted that several problems exist in traditional legislative policy implementation that may also influence the implementation of voluntary reform efforts. For example, legislative policy implementation research has found that new laws may lack an adequate causal theory linking the targeted social problem to the proposed policy solution (Meyers & Vorsanger, 2003). Additionally, new policies may contain ambiguous directives, insufficient funding to support the reform, lack of incentives to overcome organizational resistance, and may not address the discretionary role of implementing agents or the capacity of target agencies to integrate new practices (Elmore, 1978; Hill, 2003; Pressman & Wildavsky, 1973; Sabatier, 1986; Weatherley & Lipsky, 1977).

Despite the frequency with which advocacy organizations and government entities issue voluntary recommendations designed to address critical problems, there has been little academic inquiry on the ability of this strategy to initiate systemic change. Voluntary policy implementation is more likely, (a) to be used when legislation is politically unfeasible, (b) to be revised to fit “real world” needs, and (c) to engage committed others to go beyond minimum requirements to foster innovation and flexibility (Baranzini & Thalmann, 2004; Wright, 2000). However, without the force of a legislative mandate, voluntary policy edicts have no enforceability. As a result, voluntary policy adoption may result in inconsistent or nonexistent implementation and a lack of accountability by key actors to the changes being sought (Baranzini & Thalmann, 2004; Wright, 2000).

Evaluating Policy Implementation

Policy implementation scholars have long grappled with the task of determining and measuring the implementation or failure of various policy reforms. Two approaches are often used—one is a focus on the intermediary processes needed to support implementation (Gray, 1989), the other is to determine whether the underlying problem that generated the policy has been affected as a result of the policy's implementation (Pressman & Wildavsky, 1973). DVFRs have not yet been evaluated on either of these criteria.

An inherent challenge exists in capturing causal links between policy reforms and community outcomes, in what has been referred to as the “attribution problem” (Bovaird, 2012). Any particular community outcome is causally related to a number of different processes in addition to a policy response. This multicausality means that it is difficult to attribute any movement in community-level outcomes to a particular policy change. While this challenge occurs for legislative policies, it is particularly compounded in initiatives and reforms initiated by philanthropic organizations and nongovernmental entities (such as the recommendations issued by the DVFR) due to the “dynamic nature of community change” (Kubisch, Auspos, Brown, Buck, & Dewar, 2011, p. 146) and the lack of accountability structures for voluntary policy implementation. Therefore it can be more helpful to determine how policy reforms have affected more proximal outcomes such as generating momentum for change or fostering the development of community partnerships (Kubisch et al., 2011).

The “attribution problem” is particularly important when thinking about domestic violence homicides, because homicides in general are caused by a number of multilevel social processes (Roth, 2012). Further, it is even more difficult to measure and attribute potential societal-level shifts regarding domestic violence, such as permissive attitudes about violence against women, to the implementation of proposed DVFR recommendations, despite the fact that these societal-level changes can ameliorate some of the root causes of domestic violence (Prothrow-Stith & Davis, 2010). In related work, Allen, Watt, and Hess (2008) emphasized the importance of proximal process indicators as evidence of the effectiveness of Domestic Violence Coordinating Councils in catalyzing community change to promote victim safety. They assert that it is more helpful and realistic to assess process measures (e.g., meeting regularly and shared decision making) than it is to determine if coordination is reducing rates of domestic violence. In a later study, Javdani and Allen (2011) found that coordinating councils were successful at achieving proximal outcomes such as encouraging relationship building among stakeholders, information sharing and knowledge acquisition that may ultimately affect long range distal outcomes such as promoting victim safety and greater system accountability.

Policies are created to manage problems, and the tendency is to evaluate whether the policy was successful by seeing if the underlying problem has changed. Unfortunately, problems like domestic violence homicides are affected by multiple structural, organizational, and interpersonal factors that are beyond the reach of a single change effort. The focus on the evaluation of an end-outcome as the primary indicator of successful policy implementation is unlikely to “detect finer-grained successes or failures” (Berkowitz, 2001, p. 223). These intermediary steps may accumulate over time, leading to important system changes. In this vein, one of the leading scholars of domestic violence homicides, Websdale (2012), states that the value of DVFR processes, like DV Coordinating Councils, lies in their ability to mobilize all systems players in one space to collectively identify change and foster more meaningful interdisciplinary collaboration. Therefore, one way to evaluate whether a policy has been or can be successfully implemented is to focus on process measures that would be needed to move the reform into practice.

A first step in the voluntary policy implementation process is the prioritization of the reform by community partners (Cohen & Austin, 1994) because of the inherently discretionary role of implementing agents (Elmore, 1978; Lipsky, 1980). Research on the implementation of voluntary recommendations in a large state child welfare system showed that implementing agents’ perceptions of the priority of the reform were an important indicator of long-term implementation success (Cohen & Austin, 1994). Leaders in organizations and communities who support voluntary reforms can influence prioritization for community change agendas. Allen (2006), in her analysis of the efficacy of Domestic Violence Coordinating Councils, found that having the endorsement or support of an elected official or an organizational leader resulted in higher prioritization and ultimately reaching identified goals.

In this study, we focused on three intermediary steps that may contribute to policy implementation: The prioritization of a state-wide DVFR's recommendation at both the county level and within respondents’ organizations, and respondents’ perceptions of whether a DVFR recommendation had received specific resources to focus on its implementation.

Context of the Study

In 1997, the Washington State Coalition Against Domestic Violence (WSCADV) began documenting domestic violence-related fatalities throughout the state using a variety of data sources, including news accounts and crime statistics. A domestic violence fatality was defined as: (a) all homicides in which the victim was a current or former intimate partner of the perpetrator; (b) homicides of people other than the intimate partner that occur in the context of domestic violence or in the midst of a perpetrator's attempt to kill an intimate partner; (c) homicides occurring as an extension of or in response to ongoing intimate partner abuse; (d) suicides of abusers that occurred in the context of IPV. This definition included the deaths of persons who may have not been directly involved in the domestic violence such as children, other relatives, and community members. From 1997 through June 2004, 314 DV-related homicides occurred in Washington state, 225 of which were the murder of one intimate partner by the other. The majority of those killed by a current or former partner each year were women; 42 men were also victims of intimate partner homicide (Washington State Coalition Against Domestic Violence, 2004).

In 1998, WSCADV began hosting DVFR teams in areas of the state that had experienced a DV-related fatality. These reviews generally occurred at the county level, although some rural areas of the state created multicounty teams. The DVFR process was designed to bring together key people in local social service, advocacy, and legal systems for detailed examination of a fatality. Approximately 40 to 50 DV-related homicides occur in Washington state each year and this number has remained relatively stable since the DVFR was introduced in the state (WSCADV, 2004, 2011). Given the time- and process-intensive nature of the DVFR, not every DV-related homicide was reviewed by a DVFR team. Instead cases were selected for review using the following criteria:

• The death fit the WSCADV definition of a domestic violence fatality;

• The legal system had identified the perpetrator;

• No criminal prosecution was occurring that could be affected by a DVFR. As a result, cases reviewed involved the suicide of the perpetrator, or the case was closed with no appeal pending. An exception was made if the prosecutor in charge of the appeal agreed that a fatality review would not affect issues under appeal and gave permission for the review.

• The fatality was as recent as possible, given the other constraints.

Emphasis was placed on selecting diverse cases both in terms of demographics of the parties involved as well as their experiences. For example, some cases were reviewed in which the parties had multiple contacts with various systems and some where the individuals involved were more isolated. WSCADV staff compiled a comprehensive chronology of the events that occurred prior to the homicide that was shared with the DVFR team. The DVFR met usually over the course of a day to discuss each case and to identify missed opportunities for intervention, barriers to the victim's safety, and gaps in the systems’ ability to hold the abuser accountable for their violence. Following the review, WSCADV staff summarized the issues raised during the review and sent this summary to team members.

Every 2 years, WSCADV staff analyzed the issues raised by all of the review teams to determine which recommendations were shared across a majority of teams. These recommendations were reviewed with advisory committees comprised of experts in the field and finalized in statewide reports published in 2000, 2002, and 2004 (90 total recommendations were issued in 2000, 190 in 2002, and 58 in 2004 DVFR reports). WSCADV distributed fatality review reports to every DVFR team member and advisory committee member. In addition, the reports were sent to every community-based domestic violence program in the state of Washington, and these programs were asked to share the information in their local community. The DVFR reports were also posted to WSCADV's website and available for free download. Following the biennial release of each report, DVFR staff presented key findings, recommendations, and strategies for implementation of the recommendations statewide through conferences, meetings and work with individual organizations.

Method

This study was designed to assess the degree to which professionals who had participated in at least one DVFR from 1997 through October 2003 perceived the prioritization and implementation of the recommendations. The survey and research methods were approved by the Institutional Review Board of the University of Washington. A web-based survey was used to assess prioritization and implementation of recommendations from the statewide reports. Because survey burden would have been unacceptably high to evaluate all recommendations included in the reports, six recommendations were selected based on input from WSCADV staff (DV experts in Washington state). Staff chose recommendations that they believed captured the most significant issues in the state at the time of the study. See Table 1 for the listing and explanation.

Table 1.

DVFR Recommendations Evaluated in This Study.

1) Court evaluators trained in domestic violence

Court appointed evaluators adequately take into account the safety of domestic violence victims and their children.

2) Domestic violence programs and LEP proficient individuals

Domestic violence resources are available for battered women with limited English proficiency.

3) Law enforcement and LEP individuals

Adequate interpretation for LEP individuals is provided by law enforcement.

4) Probation and post sentence supervision

The probation department provides adequate post-sentence supervision.

5) Suicidal abusers

Law enforcement is knowledgeable about suicidal abusers.

6) Teen dating violence

Adequate training has been provided for people who work with teens on the dynamics of teen dating violence.

Note: LEP = Limited English Proficient.

Sample

The sample consisted of individuals (n = 220) who participated in a DVFR team from 1997 until 2003. A total of 133 individuals completed the survey, for a response rate of 60.5%. Participants came from both metro and nonmetro counties of the state and represented the following professional affiliations: community and criminal justice based domestic violence advocates, judges, medical health care providers, batterers treatment providers, child protective service workers, university academics, and public/private social service administrators. Table 2 describes the participant characteristics.

Table 2.

Sample Characteristics (n = 133).

Characteristic	N (%) of sample
Gender
Male	45 (34.0)
Female	88 (66.0)
Race
White	107 (80.5)
Asian American	7 (5.4)
Latino/Chicano/Hispanic	5 (3.8)
African American	4 (3.1)
Multiracial	16 (1.5)
Declined to state	2 (2.3)
Metro/nonmetro
Metro	88 (66.0)
Nonmetro	45 (34.0)
Organizational affiliation
Law enforcement	26 (19.25)
Community based DV advocate	16 (12.3)
Prosecutors	12 (9.2)
Judges	10 (7.7)
Medical/healthcare provider	8 (6.2)
Criminal justice based DV advocate	7 (5.4)
Batterer's intervention programs	6 (4.6)
Probation officers	4 (3.1)
Mental health providers	4 (3.1)
Child protective services	2 (1.5)
University academics	1 (0.8)
Public/private administrators	1 (0.8)
Other (e.g., shelter staff, public health workers, etc.)	32 (24.6)

Note: DV = domestic violence.

Survey Development

Due to the specificity of the recommendations to be analyzed in this study, no pre-tested survey instrument existed with already established reliability and validity. The survey consisted of 96 questions designed specifically for this project. The survey was reviewed with WSCADV staff members and other DV research experts to ensure its content and face validity. It was pretested by WSCADV staff not affiliated with the DVFR to review its length, clarity, and usability. The survey was designed to assess the following variables: policy recommendation prioritization at the county and organizational level, countywide implementation priority, implementation (i.e., the recommendation is currently being practiced) and the intermediary process indicators for implementation (i.e., committed resources in support of the recommendations, met internally, or met with other organizations about implementing the recommendation). Each respondent was asked to strongly agree, agree, don't know/ unable to evaluate, disagree, and strongly disagree to the following statements for each recommendation found in Table 1. The following are examples of the types of questions that were asked for each construct. The full survey is available from the first author.

Countywide Recommendation Priority: This recommendation is or should be a priority in my county.

Countywide Implementation Priority: My county has prioritized implementing this recommendation.

Organization Implementation Priority: My organization/institution has prioritized implementing this recommendation.

Process Implementation Indicators: (a) My organization/institution has committed resources in support of this recommendation. (b) My organization/institution has participated in meetings with other organizations to discuss the recommendation. (c) My organization/institution has discussed this recommendation internally.

Implementation (of a specific recommendation): Such as: Are responding law enforcement officers routinely screening for suicidal tendencies when responding to DV calls?

The demographic section of the survey asked for professional affiliation, county of residence, how many DVFRs the person had attended, and years in current position.

Survey Administration

An invitation to participate in this study was e-mailed to a list of former DVFR team members. Reminder e-mails were sent automatically by WebQ (the software program used) every 2 weeks to participants who had not completed the survey for a total of three times. The survey was conducted from January to March, 2004. All participants who did not complete the web survey, along with those who requested them, received hard copies of the survey. All data from the electronic survey were stored in a tab-delimited ASCII database prior to being imported into SPSS where additional survey responses from the hard copies were entered.

Data Analysis

The survey results were analyzed quantitatively using both descriptive and inferential statistics. Chi-square was used to assess associations between the variables. All survey results were compiled and analyzed using SPSS version 13.0. The percentage of agreement, disagreement, and don't know/unable to evaluate were calculated from totaling the percentages of strongly agree and agree and strongly disagree and disagree responses. In the tables, only the percentage agreeing is reported.

To identify factors associated with issue prioritization, data on the professional affiliation of respondents were used to determine if profession influenced prioritization of the recommendations. To test for differences based on professional affiliation, a variable was created for criminal justice professionals (1—judges, prosecutors, probation officers, and law enforcement) and domestic violence advocates (0—both system-based and community domestic violence advocates). Due to the small sample size, it was necessary to collapse professional affiliation in this way. These professional affiliations comprised the majority of DVFR team members.

Results

Implementation at the County Level

Table 3 presents perceptions of respondents about the efforts to prioritize and implement the six recommendations at the county level. All of the recommendations received relatively high degrees of perceived countywide prioritization, ranging from 97.7% of respondents agreed that it was a priority in their county that domestic violence programs be accessible to Limited English Proficient (LEP) individuals to 71.8% who believed that it was a priority for the probation department to provide postsentence supervision in their county. While the majority believed that all of these recommendations were a priority, views were mixed as to whether the county had made any effort to implement the recommendation. The percentage who believed the county had made any effort toward implementing the recommendation ranged from 15.6% for the recommendation on teen dating violence to 73.6 for the recommendation on domestic violence programs extending their services to LEP individuals. A majority of respondents felt that their county had made progress on implementing only two of the recommendations—DV services to LEP individuals (73.6%) and law enforcement becoming knowledgeable about suicidal abusers (55.1%).

Table 3.

Percentage of Respondents Who Agreed That Their County Prioritized the Recommendation, Prioritized its Implementation, and Had Made Any Effort Toward Implementation (n = 133).

Recommendation	County prioritized recommendation (%)	County made any effort toward implementation of recommendation (%)
1. Court evaluators trained in DV	81.4	26.4
2. Domestic violence programs and LEP proficient individuals	97.7	73.6
3. Law enforcement and LEP individuals	96.1	32.8
4. Probation and postsentence supervision	71.8	19.4
5. Suicidal abusers	94.6	55.1
6. Teen dating violence	88.5	15.6

Note: DV = domestic violence; LEP = Limited English Proficient.

Implementation at the Organizational Level

Table 4 reports on the percentage of respondents who agreed that their organization had prioritized the recommendation and taken intermediate steps to implement it. The level of prioritization at the organizational level was lower, overall, than prioritization at the county level. For instance, 94.6% of respondents agreed that the recommendation on law enforcement and suicidal abusers was a county priority, but only 31.5% thought it was a priority of their organization. Only one recommendation (DV services to LEP individuals) was perceived as a priority at their organization by the majority of respondents.

Table 4.

Percentage of Respondents Reporting That the Recommendation is a Priority for the Organization and Whether Intermediate Implementation Steps Have Been Taken (n = 133).

		Intermediate implementation steps taken
Recommendation	Priority for organization (%)	Committed resources (%)	Discussed recommendation internally (%)	Participated in external meetings (%)
1. Court evaluators trained in DV	14.2	16.6	23.3	21.8
2. Domestic violence programs and LEP proficient individuals	56.7	49.7	64.6	39.1
3. Law enforcement and LEP individuals	39.4	36.8	60.2	50.4
4. Probation and postsentence supervision	12.7	12.0	27.8	28.6
5. Suicidal abusers	31.5	29.3	45.1	43.6
6. Teen dating violence	27.6	29.3	39.1	42.1

Note: DV = domestic violence; LEP = Limited English Proficient.

Respondents reported that their organization had taken some intermediate steps to implement the policy recommendation. If internal action was taken, it was mostly in the form of discussing the recommendation internally or with others outside the organization. The recommendations that court evaluators be trained in domestic violence and that the probation department provide adequate postsentence supervision were the least likely to have had any intermediate implementation steps taken.

Professional Affiliation and Organizational Prioritization of Recommendations

Criminal justice professionals and domestic violence advocates had differing levels of support on which issues they saw as organizational priorities (see Table 5). For example, domestic violence advocates had higher levels of agreement that the recommendations regarding teen dating violence and domestic violence programs working with LEP individuals were organizational priorities compared to criminal justice professionals who reported greater support for the recommendation regarding Law Enforcement and LEP Individuals. No significant associations were observed between organizational prioritization and years of experience and number of reviews attended.

Table 5.

Cross-Tabulation of Professional Affiliation by Whether the Respondent's Organization Has Prioritized the Recommendation (n = 75).

Recommendation	Criminal justice professionals (n = 52)	DV advocates (n = 23)	χ 2 †
1. Court evaluators trained in DV	9.6%	9.6%	7.32
2. Domestic violence programs and LEP proficient individuals	52%	86%	13.74**
3. Law enforcement and LEP individuals	38.4%	65.2%	11.58*
4. Probation and postsentence supervision	‡	—	—
5. Suicidal abusers	28.8%	39.1%	1.72
6. Teen dating violence	11.5%	60.8%	19.351**

Note: DV = domestic violence; LEP = Limited English Proficient.

^†df = 1.

^*p < .05.

^**p < .10.

^‡Cell size insufficient for χ² test.

Discussion

The goal of this study was to evaluate whether recommendations created by a state DVFR had mobilized change at the county or organizational level. The recommendations differed in the degree to which respondents felt that they were important in their organizations and the larger community. Largely, the recommendations were deemed to be county priorities, however, there was much less evidence that the recommendations were prioritized at the organizational level. While only two of the recommendations were perceived to be implemented by the majority of participants at the county level, investigation at the organizational level showed that intermediate steps necessary for implementation were being taken.

Across the board, the survey respondents reported high levels of county-level prioritization for the six DVFR recommendations, indicating that there is congruence between the issues identified by the DVFR and community-level change agendas. At the county level, the DVFR either successfully reflects, or has effectively catalyzed community prioritization of these six key recommendations given the level of endorsement these reforms received by respondents.

Change at the organizational level is more difficult to see in these results. Respondents were less likely to report that their organization had prioritized and worked toward implementing the recommendations. In part, this finding may be explained by the fact that each recommendation may not be equally relevant to each organization. The cross-tabulation of professional affiliation in Table 5 supports the disciplinary nature of some of the recommendations and could help explain differences in organizational prioritization.

Despite the discrepancy between the levels of county and organizational support for the recommendations, the high level of prioritization at the county level indicates that the recommendations have been identified as issues of importance for the community involved in the coordinated response to DV. While it is impossible to conclude that the DVFR is the catalyst for issue prioritization, the goal of the DVFR is to raise awareness of systems’ failures, generate momentum for the development of new reforms, and validate existing efforts in key areas. In this sense, the DVFR may reinforce community reforms already being proposed by providing a credible source to justify more attention being paid to these issues, and thus influencing what the domestic violence change agenda should be.

Issue prioritization alone may not translate into organizational and institutional changes, as demonstrated by the data in this study on implementation. The policy implementation literature suggests that policy changes do not happen without a significant investment of organizational resources and attention to shifting the culture of the organization to embrace these new changes (Lindhorst, Meyers, & Casey, 2008; Meyers & Vorsanger, 2003). Implementation scholars have pointed to the necessity of offering tangible incentives to encourage policy reform efforts (Wright, 2000). At the organizational level in the domestic violence realm, these incentives could range from using mini-grants to spark innovation, to providing media coverage for communities that are making positive strides to improve their coordinated response to domestic violence. Individual organizations, county task forces, and institutions need support and training around processes that are successful in helping organizations move from prioritization to implementation. For example, instituting incremental steps such as internal meetings focused on translating priorities into practice, forging interdisciplinary collaborations with other organizations and institutions to reach more long-range goals, and developing accountability systems for desired changes are all important process steps that could lead to greater organizational implementation of recognized priorities.

Next Generation of the DVFR

Since the data were collected for this research project in 2004, the landscape of the DVFR process has expanded in some areas and contracted in others, both in Washington state and nationally. In Washington state, the DVFR process previously discussed continued in much the same way through 2010. At that time, a summary report was issued that contained 11 key goals for improving the coordinated response to domestic and IPV, many of which were the same as the recommendations discussed in this paper. Throughout the years of fatality reviews, many of the same recommendations emerged from this process. This saturation underscores the potential for the DVFR process to shed light on consistent system failures and highlight strategies to promote victim/ survivor safety and perpetrator accountability. Although WSCADV is no longer regularly conducting fatality reviews with teams across the state, the review process is still made available as a tool for local communities to use. One county has held a DVFR since these changes, and there is interest in implementing the review process in at least one tribal community. The research reported here was the first and only attempt to date to empirically assess the effect the DVFR recommendations had on systems changes in the state. Through ongoing discussions, we have learned that the DVFR has served as an educational tool to raise awareness about lessons that can be learned from DV-related fatalities, validated existing community lead efforts to reform systemic gaps, and acted as a “friendly thorn” to encourage systems’ accountability.

Nationally the DVFR process has gained more prominence. Specifically the National Domestic Violence Fatality Review Initiative has continued to sponsor national conferences and act as a resource for states and jurisdictions interested in hosting DVFRs. Their website, http://www.ndvfri.org, contains useful state-by-state information on review processes, DVFR reports, and concrete tools to facilitate the development of new DVFR teams. Despite the increased visibility of the DVFR process, there is still little empirical research on the intermediary process indicators and long-term outcomes of the DVFR process.

Limitations of the Study

This is a cross-sectional study and as such, it is not possible to determine the directionality of the relationship between county or organizational priorities and the work of the DVFR. The design of the survey (the lack of random sampling and a control group) prevents these results from being generalizable to other geographical areas. Because this study was focused on the recommendations of a particular DVFR, no standardized instrument was available. The measures created for this study may not have been nuanced enough to capture aspects of issue prioritization and implementation that could also be relevant to understanding the effects of DVFRs.

Conclusion

The DVFR process holds promise for identifying priorities that reflect consistent gaps in the coordinated community response to domestic violence that may contribute to domestic-violence related fatalities. The DVFR offers a critical opportunity for communities to reflect, discuss and ultimately learn through dialogue about what could have been done to prevent these deaths. With the growth in the number of DVFR teams, it has become critically important to evaluate their impact on community-level change in response to domestic violence. This research project is a first step in evaluating the potential of the recommendations found in DVFR reports to mobilize community and organizational change agendas and practices.

Community- and system-level recommendations, such as those found in the DVFR reports, hold particular appeal because they have the potential to bypass some of the traditional roadblocks associated with trying to build legislative consensus within divisive political environments. Further, these kinds of voluntary polices offer the benefit of “adaptive implementation” where agencies can tailor reforms to their own unique organizational or community needs. In other words, rather than try to design legislative reforms that are required in all communities, voluntary policies have the potential to be adapted to meet the array of challenges faced by diverse constituencies. On the other hand, we also learned that voluntary policy reforms struggle to reach the implementation stage and that recommendation implementation requires investments in infrastructure, support, and inducements.

One of the strengths of the DVFR is the fact that diverse community partners, from law enforcement to prosecutors to domestic violence advocates, have the opportunity to come together to identify gaps in their community's coordinated response to domestic violence. The “no blame” philosophy of the DVFR could inspire increased agency collaboration and a sense of a collective prioritization of recommendations aimed at creating safer communities for victims of domestic violence. It is in these capacities that the DVFR has the potential to contribute to institutional changes that may foster a more effective and responsive coordinated community response to domestic violence.

Biography

Heather L. Storer, MSW is a doctoral candidate at the University of Washington School of Social Work and a Prevention Trainee through the National Institute of Mental Health. She has worked nationally in the fields of dating and domestic violence prevention, and positive youth development. Her current research focuses on strategies to meaningfully engage youth as partners in the prevention of dating abuse and other high-risk behaviors.

Taryn Lindhorst, PhD, LCSW is the Carol LaMare Associate Professor of Social Work at the University of Washington, and spent 15 years providing social work services in public health settings in New Orleans, Louisiana. Her research focuses on the social construction and reinforcement of inequality, especially as this relates to issues of violence against women and health. Her mixed methods research has been funded by the U.S. National Institutes of Health and National Institute of Justice.

Kelly Starr, MSW is the Director of Communications at the Washington State Coalition Against Domestic Violence. She lead the Washington State Domestic Violence Fatality Review for 6 years, authoring the reports Every Life Lost Is a Call for Change and If I Had One More Day of findings and recommendations from fatality reviews. She has worked in the violence against women movement for the past 20 years as a community-based, shelter, and legal advocate at domestic violence programs in both Indiana and Washington State, and was a member of the adjunct faculty of Antioch University in Seattle.