Implementing A Criminal Background Check Process

In 2004, the University of Iowa implemented a program of mandatory criminal background checks for all health science students. The rationale for this was assuring the highest quality of patient care, and promoting the highest level of integrity in the health professions by determining whether students had any history of violent, threatening or other conduct that could put patients at risk. There were three motivating factors in 2004; first, the requirement by the Joint Commission that staff members undergo criminal background checks was being applied to students;¹ second, some states were implementing statutes or policies requiring background checks of University of Iowa students doing extramural rotations;² and, third, there were well-publicized incidents of criminal behavior by health science students that might have been prevented by a background check.³

The University of Iowa implemented a two-part system, consisting of self-disclosure by applicants and a criminal background check conducted by an outside entity prior to students enrolling in courses with a clinical practicum component. The background check examined public records in state and federal databases for past incidents and arrests for criminal conduct. “Criminal conduct” was defined as any non-traffic offense or arrest, any felony, any misdemeanor (serious or aggravated) regardless of whether the record has been expunged or the sentence deferred.

A “clinical practicum experience” was defined as a clinical practicum, clerkship, clinical rotation or other educational experience in which the student provides direct patient care, is supervised by a faculty or staff member, but is not always under direct observation. The requirement does not apply to students who have brief job-shadowing experiences, during which they do not provide direct patient care and are under the direct supervision of a staff member.

Prior to conducting the background check, the University obtains the student's written permission, provides required disclosures and obtains the information necessary to conduct the check (date of birth, social security number and previous addresses for seven years). An example of a “required disclosure” is the requirement that each student must receive a document summarizing rights under the Fair Credit Reporting Act, even though no review of student financial history is done.⁴

The University defined several principles for managing the background check process:

1. The two critical issues that must be considered at all times are patient safety and fairness to students.

2. All information derived from a criminal background check is confidential and is shared only on a strict “need to know” basis (defined by college procedures).

3. Colleges need to have procedures that are consistent with University policies, existing collegiate policies and principles of fairness and due process.

4. Procedures must be consistent with federal laws regarding student aid, the Americans with Disabilities Act and other acts to prevent discrimination.⁵

5. Consideration should be given to recognized issues relating to the administration of justice for persons from minority and financially disadvantaged groups.

6. There must be a rationale for and clear documentation of any decision that affects the academic progress or opportunity of a student.

7. Every case will be reviewed individually; there will be a presumption that decisions affecting academic progress or admission will be made only in rare cases.

In analyzing reports of misconduct the guiding principle is that there needs to be a relationship between the conduct and patient care. The conduct needs to be evaluated with regard to whether it suggests that the student poses a risk to patients. This requires, in most cases, collecting additional information about reported incidents and reviewing them in detail with the student to determine if there is a pattern of behavior. Often, this means assessing the student's judgment and maturity level and making a prediction about future behavior.

The University of Iowa initially worked with the following framework for analysis:

1. Minor incident (such as Possession of Alcohol Under Legal Age) (PAULA): up to 3 during the period of review, involving no violent or other illegal conduct and no suggestion of substance abuse: No action/no restriction of access to patients.

2. PAULA plus additional charge (resisting arrest, for example), repeated PAULA charges within short time frame or misdemeanor drug possession: Action: request additional information from student, and review with collegiate committee.

3. OMVUI (Operating a Motor Vehicle Under the Influence of Intoxicants), any act involving intent to harm, presence on abuse registry, presence on sex offender registry, non-violent felony: Action: request additional information from student, collegiate review, conditional admission.

4. Misrepresentation on admission materials about past: Action: denial of admission.

5. Incidents of violent crime, pattern of increasing seriousness of offenses, multiple citations in any area (including domestic violence): Action: these suggest a basis for concern about safety, request additional information, collegiate review, consider denying access to direct patient care.

One issue of concern is the confidentiality of abuse registries. Public record searches will not disclose past reports of child, dependent adult or domestic abuse in the absence of criminal charge. The records of a criminal charge become public records. Reports of abuse, even if they are determined to be legitimate, are not made public or accessible except by statute. There needs to be statutory authority for educational institutions to gain access to abuse registries. Iowa passed a statute in 2006 allowing the Iowa Department of Human Services to disclose the presence of nursing students on its registries, but the resulting data is only applicable to students from Iowa.⁶ It does not apply to students in other health science disciplines.

The costs of conducting the criminal background check were passed on to students in the form of a “miscellaneous fee” that was billed when the data was entered to conduct the check. The charge was initially set at $50 (a one-time charge) but after a year of experience, this fee was raised to $100. Costs for the checks vary widely, depending on the number of states that the student has lived in. Some states charge a fee to access public records of criminal convictions, leading to charges that ranged from $12 to $250 in one entering class.

Each Health Science College was required to develop a system for evaluating student responses to the self-disclosure requirement as well as define the range of actions possible when a student either discloses or is found to have a history of criminal conduct.

Much of the information outlined above for the University of Iowa also holds true for the development of the criminal background check process in the University of Iowa Roy J. and Lucille A. Carver College of Medicine (CCOM). Criminal background checks were conducted for all entering medical students as early as 2004 in a response to a request by university hospitals and clinics where medical students complete the majority of their clinical training. The CCOM has a long history of requesting information about misdemeanors and felonies, charges and convictions, on the Iowa secondary application; however, there was no follow-up to ensure that information was accurate and inclusive until 2004. Like the rest of the university, the CCOM was primarily interested in minimizing risks to patient safety and determining whether concerns would arise with future licensing applications. In the first year of conducting background checks, the CCOM used an external vendor; charged students $100; and turned up three “hits” that needed additional follow up. Of the three, one student was dismissed from the college; one student was required to meet with a dean throughout the first year of medical school; and the last issue was resolved with a single meeting between the student and a dean. From 2005 to 2008, a total of 35 hits were reported as a result of a background check and all were resolved without dismissal or rescinding of an admission offer. Most of the offenses were alcohol-related and all but two were reported on either the American Medical College Application Service (AMCAS) application or on the Iowa secondary application. The two unreported offenses occurred after application materials were filed and the students involved were forthcoming with information when contacted.

The CCOM will only accept applicants who meet both admission and technical standards. As part of the application process, all applicants must sign a background check release form that allows a vendor to complete a full criminal background check on those admitted to the college. If violations greater than minor traffic violations appear in the results of the background check, a copy of the report will be given to the admitted student and he or she will be allowed to respond to the information contained in the report. The secondary application for the CCOM also includes space for applicants who have responded affirmatively to a record that includes a misdemeanor and/or felony conviction to provide additional information.

Information provided in the criminal background check report is confidentially maintained in a secure place and, unless action is taken by the college as a result of the report provided, outside of the student's permanent academic file.

The Admissions Committee reviews all affirmative responses and considers timing, number and the severity of offenses listed. Of equal importance to the committee's review is the applicant's statement about the offense and lessons learned. The decision to admit or deny the applicant will be based, in part, on information provided by the applicant about their criminal record. An applicant denied admission is offered an opportunity to solicit feedback from the committee and information about how their criminal record contributed to the final decision will be relayed.

Admitted students who have criminal records reported on the background check and not reported on their application through the AMCAS or on the CCOM secondary application undergo another review by the Admissions Committee when results of the background check are received. The student is allowed to present additional information for the committee's consideration. Again, the timing, severity and number of offenses are considered. The full Admissions Committee votes on any recommended action and a quorum is necessary. The committee may decide to rescind an admission offer as a result of the student's dishonesty. The student has the right to appeal the decision through the normal appeal process.

The process followed at the CCOM is provided in detail to underscore the point that significant emphasis is placed on providing timely information to applicants and admitted students about the criminal background check and on a fair review of check results. Challenges in implementing and maintaining the policies and procedures for the criminal background check process at the CCOM include:

1. Ensuring consistency in actions taken by the Admissions Committee based on a consistent, fair and individualized review of the record

2. Determining relevance of and action to be taken with expunged and juvenile records

3. Whether and how to include information received in a student's academic file

4. How best to integrate policies and procedures with the rest of the health science programs and the national application service

5. Education of applicants, admitted students and the Admissions Committee about the relevance of the criminal background check and potential for action to be taken given a hit

Since the start of a pilot program in 2007, the Association of American Medical Colleges (AAMC) has provided a criminal background check service to both applicants and member medical schools through AMCAS. The CCOM is a participant in the expanded pilot and now directs applicants to AMCAS for completion of the background check. This is a significant time and cost-saving measure for all parties involved. There is no fee for the service and AMCAS contracts with an outside vendor to process the checks and provide information to the participating medical schools. Students need only complete one release of information and results will be sent to all the participating schools to which they've applied. Information about the number of participants and number and kind of hits provided by AMCAS is included in the table below.

Lessons to be passed on:

1. It is essential that there be clear policies and guidelines so that students know what to expect.

2. Detailed case-by-case review is necessary in almost all instances of repeated criminal conduct, even for minor infractions.

3. Staff members involved in the reviews should be experienced in student services and educated in all aspects of the criminal background check process and its impact.

4. Two states, Minnesota and Oklahoma, require that the student be given the option of receiving a copy of the results of the background check.^7,8

5. Regular review of policies, procedures and outcomes is necessary to ensure fair and equitable treatment.

6. Students will be subject to criminal background checks several times during their medical education and career: upon admission, upon residency selection, by licensure boards and when applying for privileges at hospitals. Students should be informed of the consequences of violating the law on their education, licensure and future practice.