TECHNICAL NOTE PATHOLOGY ⁄ BIOLOGY Stacy A. Drake, 1 M.S.N., M.P.H., R.N. and Kurt B. Nolte, 2 M.D. Essential Medicolegal Death Investigation Services: Standardization of a Survey Instrument Based on the Essential Public Health Services ABSTRACT: The National Academy of Sciences recommends that states assess the performance of medicolegal death investigation agencies. To aid in performance assessment, we adapted an instrument based on the CDC’s 10 Essential Public Health Services by translating the terminology to that of essential medicolegal death investigation services. This produced a survey that could be used to standardize reporting practices and services of agencies. To validate the instrument, a stratified random sample of 12 death investigation chiefs in 12 states was interviewed. This sample represented both medical examiner and coroner jurisdictions within the varying medicolegal structures. A cognitive testing process elicited how well participants could respond to and interpret the survey questions. The response was favorable in that the respondents agreed that given specific revisions toward question clarification, the instrument would be a useful and relevant tool for assessing system performance. KEYWORDS: forensic science, forensic pathology, medicolegal death investigation, medical examiner, public health, cognitive testing The medicolegal death investigation system supports both the public health and the public safety. In 2004, a Department of Jus- tice report stated that 40% of all deaths in the United States were referred to medical examiner and coroner offices and that almost half of these deaths (487,000) merited further investigation (1). An Institute of Medicine (IOM) report underscored a need for quality, standards, accountability, and professionalism in the medicolegal death investigation and noted that inadequacies of the current system affect public health and safety practice (2). Our study is a first step toward pinpointing what these inadequacies are and how they may affect policy and practice. A National Academy of Sciences (NAS) report outlined several issues facing the medicolegal death investigation system. This report highlighted deficiencies in both medical examiner and coro- ner agencies and addressed the need for ‘‘states to perform an assessment of death investigation systems to determine status and needs’’ (3). To this end, several reports (1–5) suggest a standard approach to measuring performance to achieve scientific-based improvement and public accountability. In 1998, the National Public Health Performance Standards Pro- gram (NPHPSP) developed standards to improve the quality of public health practice and the performance of public health systems (4). These NPHPSP standards permitted state and local agencies to measure quality of service in an effort to assess performance. The standards incorporate the 10 Essential Public Health Services (EPHS) published and supported by the Centers for Disease Control and Prevention (4). The EPHS overlap with some of the recommendations of the NAS report (3,4). A premise of our study is that these same 10 EPHS provide the foundation and framework for developing an Essential Medicolegal Death Investigation Services (EMLDIS) survey. We designed an instrument to assess medicolegal death investiga- tive systems and give national policy planners as well as state and county officials the quantitative and qualitative data for implement- ing or supporting various medicolegal death investigative practices. As the instrument has to be applicable across systems and states, the instrument was tested on potential users in an interview format. Methods An initial step was to adapt the EPHS to EMLDIS parameters, as shown in Table 1. As the intent of our study was to validate the instrument for accuracy and usefulness, methods of cognitive survey were used (6). Instrument development was based on the premise that respondents go through cognitive stages of information comprehension ⁄ interpretation, retrieval, estimate ⁄ judgment, and response. In considering an item, the participant would weigh fac- tors such as sensitivity, threat, and social acceptability or accuracy of questions and answers. This method permitted determining whether respondents interpreted the survey items in the way they were intended and whether the items were relevant to the field of medicolegal death investigation (6,7). Also, it permitted asking chief medical examiners and coroners whether the survey adequately reflected appropriate and relevant domains of interest. To obtain a representative sample, we selected 12 participants based on a stratified random sample of states according to two strata, state laws and type of system. Counties ⁄ districts were randomly selected, and respondents within each county ⁄ district were identified 1 University of Texas Health Science Center at Houston, School of Nur- sing, 6901 Bertner Ave #667 Houston, TX 77030. 2 Office of the Medical Investigator, University of New Mexico, School of Medicine, Albuquerque, NM. Received 5 May 2010; and in revised form 23 July 2010; accepted 8 Aug. 2010. J Forensic Sci, July 2011, Vol. 56, No. 4 doi: 10.1111/j.1556-4029.2011.01783.x Available online at: onlinelibrary.wiley.com 1034 Ó 2011 American Academy of Forensic Sciences