Holistic Admissions in the Health Professions: Strategies for Leaders

In the wake of national health care reform, development of the future health care workforce has become more important than ever. Millions of newly insured patients, many from underserved urban communities, are seeking health care services. In order to provide high-quality care to rapidly diversifying patient populations, health care professionals must be educated in environments that value diversity, and they must possess the background, qualities, and skills needed to address complex health needs.

As the primary educators of the health care workforce, colleges and universities are seeking strategies that will help them increase the diversity of their student populations and, by extension, that of future professionals. The admissions process is one component of an overall strategy to achieve these aims, as it allows universities to build a class of students with many of the attributes needed for success. One emergent strategy is “holistic review,” a flexible, individualized way of assessing an applicant’s experiences, attributes, and academic metrics and how the individual might contribute value as a student and future health professional. When applied consistently across an entire applicant pool, holistic review contributes to a “holistic admissions” process, best understood as a collection of practices and policies that can help an institution achieve its mission over time. The mission may include diversity goals or other mission-based priorities such as improving the educational environment and meeting local health workforce needs.

Although holistic admissions practices have been adopted by many medical and dental schools, evidence of their use in other professions has been limited. To address the need for evidence, Urban Universities for HEALTH,² with support from the Health Resources and Services Administration (HRSA) and the National Institutes of Health, conducted a large-scale, national study on admissions in the health professions that included not only medical and dental schools but also schools of pharmacy, nursing, and public health. The study examined how universities are admitting students into health professions programs and focused particularly on holistic admissions as a strategy for increasing diversity and cultural competence in the workforce, with the larger aim of improving access to care and achieving health equity. The results of the study indicate that diversity has increased at schools that have adopted more elements of a holistic admissions process, while variables related to student success (e.g., average incoming GPA, graduation rates) remained the same or increased (Urban Universities for HEALTH 2014).

In response to this study, the Coalition of Urban Serving Universities (USU) convened a small working group of university leaders to review the evidence and identify a set of common strategies that other leaders could employ as they seek to implement holistic admissions processes at their institutions. The group developed the following list of actions, primarily for college and university leaders and national stakeholders, including higher education associations, accreditors, and funding agencies. In publishing these strategies, it is hoped that higher education leaders will look critically at their own institutions’ admissions processes and consider adopting additional practices that may help them enroll more diverse student populations within the context of their unique missions and goals.

Strategies

To prepare a diverse health workforce that meets local needs, health professions schools should consider using a holistic admissions process to admit students

A holistic admissions process incorporates a variety of practices (including holistic review). Schools may choose to implement some practices and not others as they work to improve their admissions processes in accordance with their missions, geographic contexts, and local health care workforce needs.

Rationale

The study indicates that schools using a holistic admissions process have experienced increases in the diversity of their incoming classes (Urban Universities for HEALTH 2014). Academic measures of student success such as average incoming GPA, graduation rates, and pass rates on required licensing exams were unchanged or improved at most schools that used holistic admissions processes (Urban Universities for HEALTH 2014). These results validate similar findings from prior smaller studies on holistic admissions (Price and Grant Mills 2010; Witzburg and Sondheimer 2013). In addition, schools using holistic admissions processes reported increases in student engagement with the community, student cooperation and teamwork, and students’ openness to perspectives different from their own (Price and Grant-Mills 2010).

Health professions schools already using some elements of a holistic process may consider assessing their own admissions practices and identifying areas for improvement

Rationale

The study found variation in the ways in which holistic review has been implemented. Schools using many elements of holistic review reported that the diversity of their incoming classes had increased more than it had at schools that had used fewer holistic review practices. The specific practices evaluated in the study are supported by the literature and have already been adopted by a number of institutions. Examples of holistic review practices that schools are using and that other institutions might consider include:

• ◆Developing a mission statement for admissions that includes diversity;
• ◆Providing admissions committees with training related to the school’s mission, including diversity;
• ◆Including non-academic as well as academic criteria such as GPA and test scores in the initial screening process;
• ◆Balancing the weight of non-academic and academic criteria during the initial screening process;
• ◆Adding essay questions to the admission application that address the school’s mission and goals, including diversity;
• ◆Evaluating additional criteria related to the school’s mission and goals (e.g., global health, research mission); and
• ◆Selecting students from a waitlist on the basis of characteristics related to the school’s mission or goals.

Non-academic criteria that schools consider during the initial screening process reflect a broad definition of diversity. The criteria vary according to each school’s mission and local context as well as prevailing state laws. Non-academic criteria include:

• ◆First-generation student status;
• ◆Socioeconomic status;
• ◆Race or ethnicity;³
• ◆Foreign language ability;
• ◆Gender;
• ◆Experience with disadvantaged populations;
• ◆Origin in a community that is a health professions shortage area;
• ◆Origin in a geographic location specifically targeted by the school; and
• ◆Other attributes specific to the school’s mission, geographic context, and workforce needs.

National stakeholders (e.g., higher education associations, foundations, federal agencies) may help by working together to support schools interested in adopting a more mission-based holistic admissions process

Any resources provided by national stakeholders would not be ongoing but would catalyze a school’s transition to a more holistic process in the short term. For example, national stakeholders might consider the following: developing a core conceptual framework for holistic admissions; developing a list of best practices that could be utilized across professions; delivering training content; facilitating research; evaluating outcomes; and employing various communication strategies to inform faculty and staff as well as prospective students and their parents of the benefits of holistic admissions. Two national higher education associations—the Association of American Medical Colleges (AAMC) and the American Dental Education Association (ADEA)—have deployed highly successful training workshops. Other associations may choose to develop their own discipline-specific programs.

Rationale

The Urban Universities for HEALTH study (2014) found that one barrier to implementation of holistic review across health professions is the lack of a core conceptual framework and common definition of the practice. Respondents cited the need for evidence-based tools to assist them with implementation, continuous improvement, and assessment. Study participants also requested case studies of successful holistic admissions processes at peer institutions as well as state-specific legal resources and guidelines.

Institutions may consider what additional resources they might contribute to ensure successful implementation of holistic review

Rationale

Two-thirds of schools already using holistic review reported that implementation required the investment of additional resources. Resources varied in cost, and many schools were able to leverage existing sources of support. Schools invested resources up front for training and workshops, and some reported investing in ongoing resources, such as increasing faculty and staff time for admissions efforts (see Table I).

Table 1.

Holistic Review Resources, by Level of Investment Required

Level of Investment Required	Example Resource
Low	Participation in a holistic review workshop conducted by a national association (e.g., existing workshops by AAMC or ADEA or others being developed)
	Internal training of faculty and staff, including peer-to-peer training opportunities
Moderate	Implementing an electronic application system so applications can be processed more quickly
	Reallocating portions of existing faculty and staff FTE to admissions activities
High	Hiring additional faculty and staff
	Increasing student support services and financial aid

By working together, accreditation organizations could increase congruence among diversity, cultural competence, and admissions standards across professions

This strategy may help elevate the importance of diversity and cultural competence for health professions schools in the context of demographic and health system changes and increase clarity around diversity and cultural competence standards across the various accrediting bodies. Harmony across standards may also help university leaders fashion a coherent strategy for diversity among health professions schools that operate at the same institution.

Rationale

In response to the study, this group analyzed health profession accreditation standards for diversity, inclusion, and cultural competence and found significant variation. Some were specific and detailed while others lacked any reference to diversity whatsoever. Compared to respondents in fields without accreditation standards for diversity, more of those in fields with such standards cited accreditation as a motivating factor in their implementation of holistic review.

Additional research may help institutions improve admissions practices and outcomes

Possible areas for future research include non-academic attributes that are most predictive of student success and that could be evaluated during the admissions process; the impact of holistic admissions on the learning environment; and the impact of admissions practices on long-term workforce outcomes post-graduation.

Rationale

A portion of schools responding to the Urban Universities for HEALTH survey (2014) reported that they were not evaluating any admissions outcomes; others reported evaluating some but not others. Most schools evaluate student academic qualifications (e.g., incoming average GPA and test scores) but not personal qualities or attributes essential for success in the workplace (e.g., teamwork, openness to other perspectives). More schools using holistic review reported evaluating outcomes related to the learning environment than did schools not using holistic review.

Conclusion

The Urban Universities for HEALTH study (2014) provides clear evidence to support the use of holistic admissions practices across health professions. Data from the study provide a strong rationale for specific strategies that universities and their health profession schools might pursue to improve their admissions processes so as to increase student diversity and success and provide a learning environment where students from all backgrounds can thrive. Although more evidence now exists to support holistic admissions, a national conversation will be needed to identify the types of practices and evaluative criteria that will enable colleges and universities to continuously improve their processes. Developing an evidence-based admissions process is critically important for colleges and universities as they pursue their missions to provide the best-quality workforce for their communities.