1 Introduction

With population growth in the U.S. slowing, the population is becoming older and more diverse. Those individuals 65 years and older will increase by 55% from 2015 to 2030 and will represent 20% of the population by 2050 [1]. Consequently, the number of Americans becoming dependent on long-term care is increasing [2,3,4,5]. The methods by which care is provided to this population have evolved over the last two decades, moving from institutionalized care to increased options for home and community based networks of care. With this shift there was significant increase in the demand for individuals who provide services for older adults outside long-term care facilities and the fastest growing occupations being personal care workers (PCWs). As the population needing long-term care at home increases, so does the need for special protective measures to ensure the safety of older adults who are at the highest risk for abuse, neglect, and exploitation [6, 7].

Systems for pre-employment background screening of workers therefore play an important role in maintaining a secure and stable healthcare system [8, 9], and in the past decade national legislation has reflected this need in the changing healthcare landscape (Section 6201 of the U.S. Patient Protection and Affordable Care Act Pub. L. 111–148, 124 Stat. 119–124, Stat. 1025, enacted March 23, 2010). Most states currently require pre-employment background checks for workers with direct access to residents in nursing homes or other long-term care facilities or who provide services to those receiving federal funding in long-term care, however this does not include PCWs. With the previously mentioned shift to in home care and the increased demand for PCWs, system expansion is needed to keep up with the evolving state of long-term care.

One state where this expansion is of particular importance is Michigan, where 28.6% of households with a family member in long-term care reported that they experienced one or more forms of abuse including physical, caretaking, verbal, emotional, neglect, sexual, and material exploitation [6, 10, 11]. Michigan launched a statewide pre-employment background check system in 2006 to combat this issue, which covers licensed long-term care facilities. In this paper we discus expanding this system to cover PCWs that provide in home services.

2 Program Background

The Michigan Workforce Background Check (MWBC) system (Fig. 1) is in place to conduct the fingerprint-based background checks of qualifying individuals. The MWBC uses the job applicant’s name to check available name-based registries. In addition, it uses digital fingerprints scanning to conduct checks of Michigan State Police (MSP) and Federal Bureau of Investigation (FBI) criminal history records. The name-based registries checks include the Health and Human Services Medicare/Medicaid Exclusion List registry (OIG); the Michigan Offender Tracking Information System (OTIS); the Michigan Nurse Aide Registry (NAR); and the Michigan Public Sex Offender Registry (PSOR). After completing the comprehensive background checks, prospective employers receive either a “yes” or “no” determination about an applicant’s qualification status following the MWBC evaluation. To maintain continuous monitoring, the system includes a State “rapback” function that provides notice to an employer immediately if a current employee is subsequently arrested, arraigned, or convicted.

Fig. 1.
figure 1

MWBC registry checks screen from the system

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Michigan also requires background checks through alternative mechanisms for entities associated with the Michigan Medicaid MI Choice Waiver program, alternatively known as “MI Choice.” MI Choice allows for support and service alternatives to facility-based care for Medicaid beneficiaries (i.e., older adults and persons with disabilities) and has both personal care and community living components. Michigan requires criminal background checks through the MI Choice operating standards and through contractual provisions with waiver agents. “Waiver agents” have the authority to determine whether an individual qualifies to receive supports and services in her or his own home or in the setting of her or his choice (e.g., adult foster homes or homes for the aged). Based on the contract provisions, waiver agents and care provider agencies must conduct a name-based criminal history screening for all paid staff and volunteers who will enter the home of a MI Choice participant. At a minimum, waiver agents and care provider agencies must use the Internet Criminal History Access Tool (ICHAT) provided by the Michigan State Police in conducting such checks.

However, there is currently no uniform statewide standard for conducting background checks on direct care workers in general across programs. PCWs in Michigan are subject to a variety of background check procedures, since formal background check standards for this workforce have not been developed. The MI Choice program contractually requires name-based criminal history checks (i.e., ICHAT) for PCWs paid with program funds, but similar requirements are not in place for PCWs hired through other mechanisms. Given the shift to in-home and community based services and the increased role of PCWs in long-term care it is necessary to include more rigorous screening of PCWs in the MWBC system.

While an expansion to the MWBC that would cover PCWs can be shown to fill a gap in the current system, government system expansion does not come easy and requires a great amount of buy in and support, not only from those who will be maintaining and funding the system, but from those who will be using it and those who are the target of its use as well. One way to take the experiences of all those affected into account is through the use of User Experience (UX) methodologies. Using the proposed expansion of the MWBC system as an example, this article hopes to create a UX based model for system expansion that others can follow.

3 User Experience Approach to Expansion

When developing a government system, the developers need to show that the system has the following three elements: public value, legitimacy, and feasibility. Policymaking and the creation of government systems requires an alignment of these three elements in what Moore called the strategic triangle (value, legitimacy, and feasibility), in order to provide a meaningful and lasting outcome [12]. The same can be said of government system expansion. In order to create public value the system must create something real and substantial that the target population can make use of; legitimacy can be achieved if the system has political and public support, and feasibility requires the technical and human resources, as well as the commitment to apply those resources to the system.

Specifically, the expansion of a government system like the MWBC system can only be shown to be effective if it has the resources and the organizational will to do so. Moreover, the stakeholders need to buy in to the idea of the system and feel it will provide them with perceived benefits. One way to design a system expansion with these elements for success in mind is to take UX into account. The Nielsen Norman group defines UX as encompassing “all aspects of the end-user’s interaction with the company, its services, and its products” [13]. In a government system context, this means taking into account the feelings about the system of those affected by it and the experiences and interactions they have with that system. With the strategic success of government system expansion being dependent on stake holder perception and experience of the system therefore committing the required resources the researchers designing the Michigan Workforce Background Check Expansion (MWBCE) chose to adopt UX methodologies in order to create a system that could be seen to have public value, legitimacy, and feasibility. The research methods of usability testing, focus groups, and surveys were adopted to meet these goals.

4 Methods

As the proposed MWBCE was an expansion of the current MWBC system, we needed to evaluate the usability of current system before any additional functionality could be implemented. We conducted a usability evaluation of the MWBC system as a first step to ensure both the public value it provided users and stakeholders as well as the technological feasibility of expanding the system. This in turn leads to the increased legitimacy of the proposed MWBCE. Moreover, it is not just enough to show that the system can be expanded, the proposed changes need the support of those who will be using it, as well as those who it will effect, showing it has the public value to give it the buy in for legitimacy and insure it has the resources it needs for feasibility. To test this a stakeholder analysis consisting of focus groups and a survey was conducted. In this section, we discuss the usability evaluation and the focus groups outcomes in detail.

4.1 Usability Evaluation of the MWBC System

A usability evaluation was performed to identify any user interface design issues with a redesigned version of the MWBC system, which was upgraded to meet HTML5 coding standards [14]. The goal was to test the technological feasibility as well as the public value from the experience and interaction of the user. The six participants worked in long-term care in various capacities and all had conducted background checks as part of their job responsibilities. The hour-long sessions consisted of representative end users completing several tasks that included: creating new applications, determining employment eligibility for applications with and without hits, and managing the account.

Usability was measured based on the three components of efficiency, effectiveness, and satisfaction [15]. Effectiveness was measured as the percentage of tasks completed successfully. Efficiency was measured as the average time to perform a task and assessed based on issues observed during performance of the tasks. Satisfaction was measured by user satisfaction ratings (i.e., from post-task and post-study questionnaires that included the System Usability Scale (SUS)) written feedback on the questionnaires, and verbal comments from each session. While effectiveness and efficiency measures were quantitative, satisfaction was measured qualitatively.

The findings of the study indicated that users who perform background checks as part of their job responsibilities were mostly successful in completing the tasks and indicated that they had a favorable impression of the redesigned MWBC system [14], which was also in line with previous evaluations of earlier versions of the system [16,17,18]. In general, tasks that involved performing registry checks, locating existing records in the MWBC system, and updating hiring decisions for employees or applicants that no longer worked at the facility were relatively straightforward. However, tasks that involved making the correct eligibility determination when there was a non-disqualifying hit in a name-based registry, e.g., a misdemeanor offense that was not disqualifying to work in long-term care according to the State statute, were more challenging for some of the users [14].

After attempting all of the task scenarios, participants were asked to use the System Usability Scale (SUS) to rate their experience with the MWBC system. The SUS, created by John Brooke, is an industry standard used as a quick and reliable tool for measuring usability that can be used for small sample sizes [19, 20]. The SUS score for the MWBC system was 94.6, which is considered a very high score [14]. Overall, participants viewed the redesigned provider user interface to be is usable, accepted, and efficient. The results from the usability evaluation are mapped to the public value and feasibility of creation government system expansion and provide theoretical foundation for a meaningful and lasting outcome.

4.2 Stakeholder Focus Groups Analysis Strategy and Methods

A “stakeholder analysis” involves a researcher assessing the attitudes of various stakeholder groups about a particular program or prospective change. The broad goal of this research study was identification of the normative (i.e., how things “should be”) and structural obstacles to expanding fingerprint-based background checks to PCWs. The researchers gathered stakeholder attitudes and beliefs because program success ultimately would depend on views about the need for, viability of, and effectiveness of expanded background checks. The researchers deliberately gathered both positive and negative views, as well as feedback about the balance between the two. In order to gather a cross-section of views effectively and comprehensively, the researchers employed a mixed-methods approach with both focus groups and a survey.

4.3 Stakeholder Analysis Participant Profile

Although stakeholder analysis can take various forms, the researchers focused on analyzing the attitudes and interests of a broad cross-section of important stakeholder groups. The initial step was identification of the key stakeholder groups to be included in discussions of a potential change process. This first step resulted in the categorization of stakeholder groups as shown in Table 1 below.

Table 1. Stakeholder groups
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For purposes of the research study, Group 1 (participants receiving supports and services and their relatives and advocates) focused on individuals qualifying for in-home assistance under MI Choice. As for the other groups, Group 2 (PCWs and job applicants) included individuals hired through MI Choice, including some who had undergone fingerprint-based background checks in the pilot program. Group 3 included employees of a number of waiver agents that make waiver determinations for the State. Group 3 also included employees of fiscal intermediaries, which are entities that help individuals with money and financial matters and/or help organizations with tasks such as payroll and conducting background checks. Fiscal intermediaries may also conduct background checks on individuals hired in self-determination situations. Group 4 included owners and employees of care provider agencies working in the pilot program’s geographic coverage area. Such agencies were either firms or non-profit organizations that hire PCWs to provide supports and services for individuals. A range of NGO employees (Group 5) were part of the study, including some working from the perspective of participants receiving supports and services and some working from the perspective of PCWs. Finally, Group 6 included government employees at both the county and State levels.

4.4 Stakeholder Analysis Procedure

The researchers planned and convened five focus group sessions to gather information and feedback from the stakeholder categories listed previously (excluding the government employee category). Per methodological standards, the target size for each focus group was approximately 6–10 participants. The focus group sessions lasted between 75–90 min each. In terms of additional resources, Michigan State University provided two note takers (both familiar with user experience evaluation methodologies) and two digital audio recorders for the focus group sessions and arranged for transcription of the raw data. The notes supplemented the digital audio recordings and provided additional data for the transcriptionist. The researchers debriefed with the note takers after each session. The exact number of participants for each focus group was: twelve in Group 1, thirteen in Group 2, six in Group 3, seven in Group 4, and six in Group 5. Differences between the two slates of questions reflected differences in the nature and interests of stakeholder groups, for example questions about organizational processes would not be appropriate for the group of participants receiving supports and services.

Groups 5 and 6 were the subject of a web-based survey the researchers distributed to employees of both governmental and nongovernmental organizations with responsibilities related to PCWs and/or background checks. The survey used both closed and open-ended questions that were informed by the results of the previous focus group sessions. The researchers initially recruited 30 governmental and nongovernmental employees via email. Individual responses were delinked from the identifying information. The researchers had followed up with prospective respondents on multiple occasions. The response rate for the survey was 60% (i.e., 18 out of 30).

4.5 Stakeholder Analysis Results

General Concerns Related to Personal Care Workforce.

Multiple stakeholder groups made it clear that background checks were part of a web of general issues related to the personal care workforce. In terms of labor economics, focus group and survey participants mentioned low average pay, high turnover, and the transience of the PCW workforce as concerns. Focus group and survey participants also expressed concern over the increasing need for PCWs as the general population ages; demographics will continue to drive greater demand. Also prominently mentioned were concerns over the lack of standardized training, licensing, and certification requirements for PCWs.

PCWs expressed worries about their own safety and about the need for greater protection from family members of some participants receiving supports and services. The PCWs felt that some participants receiving supports and services also needed greater protection from their own family members. Further, PCWs worried that government funding programs do not currently cover sufficient hours of work, meaning that participants receiving supports and services are not receiving all the care they need. Personal care agencies, on the other hand, mentioned the logistical difficulties of supervising PCWs who are widely spread out as they work in homes. Personal care agencies also mentioned the economic pressures introduced by increasing minimum wages in Michigan.

Perceived Benefits of Expansion.

A widespread opinion across groups was that fingerprint-based background checks are necessary. Half of the survey respondents cited the lack of fingerprint-based background checks as problematic. Focus group participants indicated that such checks were “desperately needed” and that the current lack of a requirement for fingerprint-based checks for PCWs was “amazing.” Survey respondents similarly noted that background checks are required in related healthcare professions and that measures should be taken to limit the cases of fraud and abuse that harm the entire direct care industry. In the view of such persons, fingerprint-based background checks would legitimize the industry, improve its reputation, and professionalize PCWs. Widespread belief existed that fingerprint-based background checks improve the actual safety and security and feelings of security for participants receiving supports and services.

Another widespread belief was that background check requirement would dissuade problematic individuals from applying for jobs. Focus group participants thought that the cost of such background checks alone might deter some unfit applicants, if those costs were borne in part or whole by the workers. According to focus group and survey participants, deterrence would result in improved quality of the personal care workforce overall. Participants in multiple focus groups and some survey respondents thought that fingerprint-based background checks might serve as a source of pride and of feelings of professionalism for PCWs, as well. Background checks could function as a credential of prequalification for PCWs.

Focus group participants noted that a statewide fingerprint-based background check system might produce cost savings by weeding out unfit applicants or employees quickly, thereby enhancing the quality of the workforce and reducing turnover. Personal care agencies were also hopeful that better, standardized checking procedures might reduce the cost of liability insurance, given the potential for a better quality workforce.

Potential Concerns About Expansion.

This section discusses the types of issues and concerns the State might try to address in implementing any new background check system, with an emphasis on fingerprint-based background checks. The costs of fingerprint-based background checks and the question of who pays for the checks for PCWs were clearly the biggest concerns across all focus groups. Among survey respondents, 78% were “very” or “somewhat” concerned about both increased costs and about who pays for them, though at least one survey respondent felt that organizations that really cared would have no problem covering the costs. Each stakeholder group had different ideas about who might be responsible for covering the cost, with such ideas including the State, personal care agencies, PCWs, participants receiving supports and services, and health insurance companies. PCWs and participants receiving supports and services all expressed a clear belief that their own group could not carry the costs. Various focus groups argued that costs ultimately would get passed on to PCWs or to participants receiving supports and services regardless of who paid initially. NGOs asserted that the State and the personal care agencies were the only feasible options, given that State law prohibits job applicants from paying the costs of fingerprinting.

Focus group participants also saw a system as insufficient if it did not capture relevant non-criminal offenses on the part of a job applicant or worker. Finally, focus group participants pointed out that abuse occurs sometimes even when fingerprint-based background checks are present; as one participant observed, you cannot “forward-check” a job applicant or worker. Survey respondents also noted that you are not likely to catch the “clever” unfit actors and that background checks do not assess personality.

The researchers did not see the anticipated level of privacy concerns related to the process of taking and storing fingerprints. The expression of such worries was minimal across focus groups and even in the PCW group, though the latter group was not necessarily representative of the whole PCW population. A number of focus group participants shared the view that privacy is nonexistent in our society now anyway. However, half of survey respondents indicated that they were “very” (17%) or “somewhat” (33%) concerned about worker privacy.

In replying to a question about benefits versus costs on the survey, 56% of respondents said the benefits outweighed the costs, 33% were unsure, and only 11% said the benefits did not outweigh the costs. Some survey respondents mentioned direct balancing tests. For example, the decision might come down to weighing the prevention of misconduct against access to service concerns.

5 Conclusion

Using a UX framework can help to identify areas where public value, legitimacy, and feasibility are strong and need more attention. This UX framework helps to identify user and stakeholder experiences and drive design forward in a way that will lead to the success and stability of the implemented expansion. Getting these experiences helps to triangulate where public and political will are strong or lacking, and helps to find the required resources for implementation. Starting with an evaluation of the current system provides the designers with insight into the technological feasibility moving forward, as well as feedback about the value of the current system to those who use it and all those it affects. Using usability evaluation, focus group, and survey UX methodologies we were able to identify where the proposed MWBC design expansion for PCWs was strong and also areas that need more attention moving forward.

The usability evaluation highlighted that users are willing to take the time to learn the current MWBC system because they recognize the benefits in terms of time conservation, consistency, and patient safety, demonstrating that the MWBC system has the public value and the backing to show the expansion has legitimacy. Users of the MWBC system also stated that it is user-friendly and works for a diverse group of end users, showing that the current system has the technological feasibility to serve as the basis for expansion.

The UX methodology of focus groups and survey provided a great deal of insight into unforeseen opinions and concerns with the MWBC expansion among stakeholders highlighting their usefulness in expansion design. While originally hypothesized to be a larger issue, privacy was shown to be of little concern to all stakeholder groups, whereas cost was the main concern. Stakeholders across groups had concerns about the increased funding needs and who would be responsible for covering the cost showing a feasibility challenge in terms of resources and ownership. Stakeholders did believe that the benefits of expansion outweighed the costs, though, as a widespread opinion throughout the groups was that fingerprint-based background checks are necessary; the MWBC expansion was shown to increase the public value of the current system and had the legitimacy in terms of public and political backing to be implemented. Moving forward, additional research and planning will have to be done in the area of cost. By continuing to highlight the user experience, we will focus on designing an expansion where the resources associated with cost and ownership will be mitigated as much as possible to increase feasibility.

Highlighting all of these experiences as part of a user centered design of system expansion shows that UX methodology can be used by other states and organizations to better test the public value, legitimacy, and feasibility of their proposed system expansions. By first testing the current system for public value and feasibility, and then getting feedback from those the proposed expansion effects on the legitimacy and feasibility of implementation, a more strategic, valuable, and successful system can be designed.