Establishing a Quality Assurance and Training System to Sustain the FAIR System for Determining Incidents of Family Maltreatment in the U.S. Army

Background and Purpose: Implementation science models emphasize that developing and disseminating evidence-based interventions (EBIs) is a recursive process spanning early development through EBI sustainment. However, in practice, most research focuses on efficacy and effectiveness rather than sustaining EBIs once they are widely disseminated. Research has shown that EBIs tend to have lowered dosage and that drift is common as implementation moves from tightly controlled trials into real-world settings. This is true for EBI implementation in the military, where policy mandates a wide variety of prevention-focused EBIs, typically with little support or oversight for ongoing evaluation and monitoring of fidelity.

FAIR, an evidence-based system for determining whether incidents of partner and child abuse and neglect meet criteria as maltreatment, is mandated for use across the U.S. military’s Family Advocacy Program – the country’s largest family maltreatment service system. FAIR can be consistently used by multidisciplinary, local determination committees and has been shown to reduce recidivism by approximately half. When the U.S. Army transitioned to this system in FY22, it was the first service to require annual quality assurance (QA) to support FAIR sustainment. The Army Family Advocacy Program partnered with researchers to establish a QA system supported by feedback and responsive training. This paper will describe the QA and training system and demonstrate the impact of QA on FAIR implementation to date.

Methods: In FY22, 33 sites transitioned to FAIR and were included in data collection. QA began in FY23, which included an additional 12 sites that had been previously implementing FAIR. Observers (members of the research team) monitored determination meetings, completing fidelity checklists and recording both the committee’s and their own determination for each incident. During QA, sites that did not meet fidelity completed an improvement plan tailored to address identified needs and were then reassessed.

Results: FAIR fidelity improved across the three years of observation, with more sites achieving fidelity more quickly between FY23 and FY24. The accuracy of committees’ determinations improved as well: in FY23, accuracy was 86%, which is below the 90% threshold for “excellent;” in FY24, accuracy was 93%. Determination committees more quickly and consistently met fidelity for following procedures compared to committee functioning, which requires having appropriate and sufficient information to make a determination and doing so correctly based on the available information.

Conclusions and Implications: It is feasible to establish a quality assurance and training system to support EBI sustainment within the country’s largest family maltreatment service system. Annual QA, coupled with feedback and training, helped local committees implement FAIR with fidelity and accuracy. Facilitators and challenges to system-wide QA will be discussed, including FY25 changes in response to recent executive orders.