Latest / ABA Business Leaders / How Do We Define Quality ABA Services
Transcript
- speaker-0: I approach this in a way that I think is unconventional. I think it goes against the grain, probably. Focusing on number of goals mastered, even number of skills mastered, is is totally a distraction. It's missing the mark because what gets measured gets selected. speaker-1: Thanks for joining us on ABA Business Leaders. speaker-2: We provide mentorship, courses, handbooks, billing support, credentialing, HIPAA support, web design, and more. Everything you need to build an ethical and sustainable ABA practice. speaker-1: You can find all of our resources at threepiesquared.com. speaker-2: Don't forget to subscribe and share this podcast with other ABA business owners. speaker-1: We'll see you next time and remember you don't have to build your practice alone. Hello, everyone. Welcome to ABA Business Leaders brought to you by 3Pie Squared. I'm April. And today we have with us a special guest, Brian Silba. He is the founder and CEO of NASCAR, the National ABA Service Quality Network. He's a behavior analyst who specializes in the assessment and treatment of autism spectrum disorders. He has a book. speaker-2: Steven. speaker-1: ⁓ quality control for behavior analysts, how to manage behavioral intervention, quality and autism service settings. And there's so much more about Bryant's experience in the field. And if you want to learn more about him, you can look at the bio in our show notes. ⁓ but welcome Bryant. Thanks for being here today. speaker-0: Hi, Stephen and April. It's a it's a real pleasure to be with y'all and ⁓ thank you for the opportunity. speaker-1: Yeah, absolutely. So really we're just gonna jump in today. Our topic for today is quality. if you have been a listener for even a short time, then you'll know that that's something that we talk about a lot is how important it is to provide quality services. And you may think, ⁓ well, that's a no-brainer. That's what we all wanna do, right? That I mean, that's what we're here for is to help. And a lot of a lot of those of you listening, you know, even started your own business because you wanted to be able to have more control and how you are how you're speaker-2: My better services, higher quality. Right, yeah, we hear that very often. Yeah. speaker-1: Do you think it's a little better than the place you weren't at before? ⁓ and and so that of that brings us to our conversation where we often talk about, well, how do you know you're providing quality services? And, you know, a lot of times we don't know. Right. ⁓ and and so, you know, not only what does quality services what do they look like, ⁓ how do you know you're providing them? You know, if you're not providing them, then ⁓ shoot, what do I do now? So when we invited we've had a conversation in the past with ⁓ with Bryant and learned more about Naskin and ⁓ been following his work and super excited about ⁓ what you guys are are doing in the field. And so we invited Bryant on to to have this conversation 'cause I think he's the he's the perfect guy for this conversation. So thank you so much. And ⁓ I don't know, let's just jump in. What w w what's quality, Bryant? How do you know? Yeah. speaker-0: I don't I don't. Yeah. ⁓ yeah, excellent question. You know, and and thank you for your kind words as well. well, ⁓ so ⁓ I I've been in the field for for about nineteen years or so, in various roles as a you know, an early childhood ⁓ interventionist, what we would call like a behavior tech today, ⁓ before there was the RBT credential. And then I got my ⁓ I was working in homes and early childhood intervention and ⁓ became a clinical ⁓ supervisor, got my B C B A th, you know, after completing coursework at FIT and eventually made my way back into grad school to get a PhD in special education and autism and ⁓ started a resear a couple of research lines there, clinical research lines. And I carried that through to ⁓ my role as ⁓ assistant professor at University of ⁓ Texas at San Antonio around twenty seventeen. And ⁓ t ⁓ around twenty twenty I realized I wasn't gonna get ⁓ tenure and ⁓ and so I decided I'm going to, you know, leave academia and get back into clinical practice. And around that time, ⁓ I was consulting with ⁓ a good friend and colleague, ⁓ Robbie El Fital at the time. And ⁓ Yeah, we had a few meetings and started to narrow in on how I can be helpful and what our projects may be. And ⁓ at some point he we jumped on a call and he said, ⁓ Brian, or how do you know if a ABA organization is delivering high quality services? He said, How do you know if it's a high quality company? ⁓ how do you distinguish between varying degrees of quality as you're looking at different companies? And I thought that's a really good question because families wanna know that. Families wanna be able to differentiate between providers, ⁓ A B providers, in the same way they wanna differentiate between childcare and school and plumbers and arborists and you name it, right? And so it was a great question. And I thought, I don't know, have no idea. 'Cause ⁓ I don't know, you know, I I just had never in graduate courses, even as a professor myself, I'm not sure I ever mentioned the word quality in anything that I ever taught. you know, for accumulatively eight years in different roles. And it's because the field ⁓ in our site peer reviewed literature and our textbooks, ⁓ we really didn't they didn't really cover the topic of quality or quality assurance in the ABA service delivery. ⁓ so that that was a a spark for ⁓ Robbie and I to conduct some research on quality and and answer that question for ourselves. What what is quality? speaker-2: That's great. Yeah, like in engineering, that's my my background. Like quality is is so important, right? Like having key performance indicators to make sure that we're ⁓ our our quality ⁓ our output is ⁓ to the degree that we need it. And you know, ⁓ that like you said, it it's it's a s it's a struggle for the companies, but it's also super important for the clients. And when It's hard. You know, like with a regular doctor, you can fill out a satisfaction survey and you can right, but when you're working with children, right, it's really hard to say, okay, fill out this 20 page satisfaction survey and tell me how you feel about our right. Like so it's it's really hard to figure that out. ⁓ and is that is that the only way to look at it anyway, right? What are those factors that we should be looking at? Is there like high level Do you have like some key metrics that you look at? speaker-0: ⁓ what you're talking about there is like is ⁓ it's on an aspect of quality which is a personally defined standard. Personally defined standard. Everyone has different standards actually. I don't know if that's ⁓ is the correct way to say everyone has different standards, but there's varia there's a c variability in what people expect from a service, you know, what good looks like. And ⁓ so ⁓ that's a nice segue into like or I think we should look at that within the broader context of a framework for quality. So we can interpret that and and look at quality from a variety of different angles. And we'll at some point we will get to this Q KPI question of how does that fit into ⁓ monitoring attainment of standards within a quality assurance framework. So ⁓ when Robbie, as I was mentioned when Robbie and I launched that, ⁓ launched some research We wanted w we it ultimately resulted in a paper published in, I think it's twenty twenty two in the behavior analysis in practice. And I forget the actual title of our paper, but it was exploring quality in the ABA service industry, something like this. And what we wanted to do is sample from sources in ABA research and A BA practice how behavior analysts are talking about or conceptualize quality. ⁓ so we could ⁓ sort of start a conversation about well, hey, there's considerable variability in how we talk about quality. Quality ⁓ actually is underrepresented in research in our in our peer reviewed journals. And so probably a lack of consensus on a definition of quality and up b an ability to operationally define quality is a barrier to the industry being able to objectively and verifiably sort of monitor quality over time and ⁓ manipulate ⁓ or design, I would say this way, design service delivery systems that enable clinicians, clinical directors, ⁓ operators to engage in those practices necessary to meet standards and deliver quite and like understand the variables. How what are the variables that are influencing quality service practices? So that not could we need it we didn't have an evidence base. There wasn't an evidence there's a huge evidence base for like 70 years building on the validation of behavior change procedures and assessments. But very little research validating the systems and the context that support practitioners using those validated procedures and assessments over time, you know, to the satisfaction of other people based on their personally defined standards. Yeah. So, okay, so now I'm gonna I'll go back back up a little bit. Okay. So in the paper we d we said this, okay, here's a starting point. You can define quality at least at the organizational level at the as the extent to which an ABA organization meets professional and consumer standards over time in response to a receiving system. This is the recognition that there are external factors and contingencies in a macro system or a market that have an influence on what we do in any given organization. And then while Max so may ⁓ attaining those standards over time while surviving challenges in the marketplace to keep your organization thriving, ⁓ but also maximize financial health over time. And the focus on that is really about the ability to continue to reinvest to invest in quality assurance over time. It's not about the biggest profit. Sometimes when I first started when I first published that paper with Robbie and I started giving talks, they're like, why is this tied to profit and whatnot? And I was like, wait a minute. That's not the point here actually. We're talking broadly financial health is you have a healthy profit margin, a healthy stable revenue streams, and you have a ⁓ responsible growth over time and the investment in quality assurance. So you both you have operational goals and you have clinical quality goals. And both of them are receiving investment and attention and they go together instead of one shooting off. Yes. And you have ⁓ rapid, uncontrolled, sort of unreasonable growth in operations while quality lags behind. ⁓ so that's that's been a starting point and that's been sort of an anchor for everything that I've done in quality and sort of research and practice since. speaker-2: Yeah, I I I like how you you say like it the company has to be sustainable, like there has to be some profit in the company so you can reinvest. And so like what w I assume like you said, when you started talking about this, there was some pushback. Whoa, whoa, whoa. Like it it we have to focus on quality clinical services. Why are you bringing up profitability of my company in this, right? Like that's evil, that's bad. ⁓ can you talk more about that? speaker-0: Yeah, yeah. you know, I will ⁓ say that I'm not a finance guy. I'm not a financial health of the organization is not my expertise. ⁓ my expertise is more focused on designing the systems and the processes within a quality assurance ⁓ system. And ⁓ one of the one of the things I'm learning is that it is difficult To draw a direct line between, let's say, like quality assurance initiatives or quality improvement initiatives and key business results from a financial perspective. It's tough because if ⁓ what I found is if you have a ⁓ like a robust quality assurance system, like a quality management system that is developing across your organization, ⁓ it happens as a result of everyone starting to feel like Quality is everyone's job. Everyone has a role. Everyone plays a part. And no matter where you are in the organizational chart, you do have influence on service quality, especially with respect to what's exactly right in front of you. There are constraints that systems place on you, but you do have control over the quality of your interactions with other people and the outcomes or the work outputs of whatever your responsibilities or tasks are. You have a degree of control, you know. ⁓ and we can touch we can get ⁓ it would be fun to talk ⁓ like double click on this later. ⁓ but in the quality field there are fundamental principles of managing for quality that anyone anywhere in an organization can apply at any time to everything that they do. ⁓ so I I think that's a useful concept to apply. But but yeah, you you end up having ⁓ to build a quality assurance system, you end up having quality improvement initiatives that focus on often process improvement. And that happens through cross functional teams where you have meaning people from different departments departments. If you in order to improve a for example, a training process in an ABA organization, you may have to work with the training team, but the clinical t clinicians ⁓ who s are the recipients of the trained technicians, but also the clinical director and then HR and recruiting and ⁓ people from other departments outfit because everybody has a different perspective. And also ⁓ like there's this general underlying philosophy in quality, in the quality field outside of ABA, that everyone's a customer. Your client is not a customer. They are a customer. ⁓ and when if you are ⁓ training technicians in your organization, the receiving system, the service delivery system where they go out of training and into direct treatment with clients in a maybe a two tiered model supervised by BCBAs, those B C B A supervisors, they're consum they're customers. They're receiving an output from a process and expecting they have a standard. The organization has a standard, maybe. And then the clinician has a standard for what they need to get their job done. And the technician has a standard. speaker-2: Like if if you were talking to a smaller or ABA organization, like is there where where would you recommend we start to measure that or to define our process? speaker-0: In my role ⁓ as ⁓ founder and CEO of the ⁓ of NASCAR National AB Service Quality Network, ⁓ I have a great team. ⁓ I'm lucky to work with people that like get my brain going, get my creativity going, ⁓ ask me the right questions, and help me develop things, ⁓ models, frameworks, concepts, ideas, things that make quality easier to communicate. Tailor communication about quality to different audiences. That's really important because if you're talking with someone, ⁓ let's say a VP of whatever in an organization that's in tw you know, 20 states and they have thousands of employees, ⁓ they're they're in a total different world than someone who's an entrepreneur and ⁓ works with a couple of B C V A's and is a year or two into business or whatever, you know. Right. And then there's everything in between. So ⁓ one of the things that we've developed, and it is in, I'll say like an earliest stage, and it will continue to develop, ⁓ is something we call a quality maturity model. ⁓ and you can think of it as breaking down the development ⁓ of quality assurance practices in an ABA organization over time. and we've conceptualized it as consisting of five levels. ⁓ so the five levels are really ⁓ I'll I'll I'll I'll I'll I'll sort of talk a little bit about what they are. I'm curious what your what your thoughts are on this. and ⁓ so think of level one as an A B organization that isn't really ⁓ doesn't really have a clear definition of quality. Okay. The ⁓ supervision practices and supervision quality vary widely, but it's not noticed or recognized or quantified in any clear way because there aren't systems or processes in place. You you may be a startup and you may not even have a handbook and you've just gone for it. And so now you've hired clinical supervisors and and you don't have any real way to standardize what they're doing, evaluate what they're doing objectively, ⁓ develop them professionally. ⁓ Determine the quality of the protocol modification sessions or conducting things like this. Okay. So we'll say there's variability and supervision in that organization. ⁓ a lot of this key decisions by the organization, by leadership, by the supervisor, by employees, is made maybe by more perception, intuition, less data driven. No, there may not be much data, ⁓ especially organizational or like operational data. And but they think they're doing well. Well, you have you have to like sort of tell yourself that every day. You know what I'm saying? So you can get over the h get up the hill. You're climbing a hill and given everything you got to try to survive and build something that you like your to your point earlier, Stephen, is like people start mo I believe most b behavior analysts start a company because they're like, this can there must be a better way to do this. Maybe I can do it. Or maybe I can attract the right people who can build something better. speaker-2: Yeah. speaker-0: That means they're going right into it with a continuous improvement mindset, and that's a key ingredient in quality. So that's actually a great starting point. Okay. ⁓ so they get into this and but the contingencies that are really influential on quality or operations, service delivery are things like time, billing, ⁓ trying to survive. That's that's the dominating sort of ⁓ mode. ⁓ but there's high variability and poor outcomes. Poor clinical outcomes are actually hidden. They are happening. Maybe they're not hidden, but But the outcomes aren't gonna be great. ⁓ now let's say they move to level two. So level two, they become more compliance driven. So this is an organization that's like has the budget and the wherewithal to now invite an external auditor. Go ahead and get ⁓ pursue accreditation or at least start exploring it. And so that they can start to look outside for what are standards of. practice. Where's the bar? What does good look like according to another organization outside? And maybe they can help shape us, build us, ⁓ hold us accountable, you know? ⁓ so now external standards dominate this the concept of quality in the organization. It's all about compliance, meeting someone else's standards and other in industry standards. And they're really trying to avoid errors, avoid callbacks from audits, ⁓ things like that. But the limitation here is that compliance is treated as equivalent to quality, but it isn't. It isn't quality. ⁓ it's something else. And they won't have an internal system that drives c improvements in processes ⁓ outside of like doing what they can to survive to get to the next month. ⁓ okay. So then in level three, they define quality. So the way I we think about this at NASCAR is they may have stumbled upon the ASDQ paper from me and Robbie back in 2022. And they're like, ⁓ shoot, there is a way to define quality. Okay. Or maybe they go to Naskin's website and they're scrolling down. They're like, fit for purpose. That's interesting. What does that mean? Well, that's a definition of quality from another industry from other industries. And they now the organization for themselves starts to say, we have enough bandwidth and we're mature enough and developed enough that we can start defining quality. And then they start tracking supervision, quality, treatment, fidelity, outcomes, things like this. ⁓ so there's a shift. I would say there's a developmental shift in the organization too. ⁓ we define quality internally now. Now they're internally, they're past some accreditation organization defining it for them. Now they're over that hump. They're looking at some research and they're saying, What's quality mean to us? Let's define it now. Level four, and I'm almost there. Almost there's five left. Yeah. So level four is now they're actually there's a quality assurance system that is developing. It's active. There's quality planning and quality control. There's KPIs. Now we're to KPIs, Stephen. It probably should have been some KPIs earlier, but there's a more robust sort of ⁓ system of KPIs attached to the organization now understands how to break up their processes in ways throughout the system to identify the right meaningful KPIs, track them. For the purpose of meeting standards. Supervision becomes more supervision practices, protocol modification, things like this. Parent treatment guidance becomes more standardized. Variability in practices are reduced, and reinforcement begins to be tied to quality metrics. People roll out scorecards and other contingencies for quality service practices. Outcomes become more predictable. There's continuous improvement. Level five is an optimizing system. So there's continuous improvement beyond standards. They may even have realized now that cultural selection is a phenomenon influencing what their organization does, and maybe look through a metacontingency lens. Now the leadership is more very much system and focused level. And what are we engineered? What have we engineered? What what what what are external forces causing us to do? How does that all work? Then they start to select for high quality culture. Culture is now evolving around clearly defined definitions of quality and metrics, processes, standardization. ⁓ now they have more market differentiation. They discover, hey, now we can differentiate ourselves from other providers because we have objectable, verifiable metrics of quality service practices. Their workforce becomes more stable, maybe root turnover goes down, burnover, ⁓ burnout goes down, you know. ⁓ the quality of the applicants start increasing because word gets out, these folks know what they're doing. And then they start delivering better client outcomes or at least at the very least get better at trying to quantify it and strategically allocate resources to objectively improve outcomes. speaker-1: There's so much that I want to say. But I do want to ha let our listeners be able to sit in that because I think that sometimes just knowing what that developmental process is, I love I I I love that term for it because it especially as a lot of behavior analysts like working in early intervention, that's something that we really focus on like when we're doing our programming for our learners, right? Is developmental appropriateness for for what we're what we're working on. So if we can understand what a developmental, you know track might look like for an ABA company, it one helps you to not feel so alone and and and that's part of what we do here, right? And ⁓ it kind of helps you to to n to start learning some of those things that you don't know, what you don't know. It kind of brings those to the forefront of okay, these are the things I can start looking to. And you know what? It's okay. if you're not at level five day one of opening your business. Yes. Because I think sometimes we fall we fall in it it's just as humans, right? You know, that what was it, level level one, right? Just trying to survive, right? And and you just trying to keep those door open one foot in front of the other. and sometimes ⁓ what we see a lot of times are business owners who get stuck in level one. Right. And and they don't know how to even move into level two because now we've turned into, you know, complete system of of putting out fires one after the other. And and when you're in that spot, it's hard to see outside of that. You feel like you don't have time to put anything in place, right? ⁓ we we work with people who, you know, they're they're somewhere between level three and level four and they're really striving for a level five, right? And and And and yet they they see, ⁓ man, I was stuck in level one for so long, great. Like if I would have if I could have done all of these things I'm doing now then, like, wow, we could have made even more of a difference. And so anyway, so having these levels and the definitions of these levels really for me is helping me to put all of these stories kind of within the it brings everything together, right? speaker-2: Yeah. And I I think it like for me it goes back to that vision, mission statement, understanding what it is that you want to build. When you open the door, what do you hear? You know, what are what are what what what does therapy look like to you? And really having a good understanding of what it is you're trying to build, super important. Because I think that for a lot of level ones and level maybe one point fives that I work with, it's like I I know what quality is. I I like what did you write it down? Do you do you have definitions? No, I just know it when I see it. And then they, you know, start building from ten employees to twenty employees to thirty employees to forty. And that's where we lose it, right? It's when I start to scale this and I can no longer micromanage every piece of this. Is that's where I'm finding my quality goes down, Steven. What's going on? And so it that it is because, right? You d you haven't defined it. You you don't know what this should look like. And ⁓ so having those clear levels can help and and yeah. So and then I do have one other question. Do you I have a lot of questions, ⁓ especially around KPI, but like do you think it's a fair assumption to make if I have higher educate like if my my staff are more educated, so maybe they're Bachelor's degrees, master's degrees, doctorates, and I have a better standard of supervision and I have more training for my staff that I can say I have a higher quality of services. Is is that an is that a good starting point or am I completely ignorant? Does that make sense? speaker-0: Well, definitely not completely ignorant. I'll just say it depends. Okay. It depends on I'll give I'll give some more context here. I'll give some more context. So I think it would be helpful to to put that question in ⁓ like a a f ⁓ like a a simple a framework with a couple of what I call like triads or heuristics. ⁓ you know, for so for the A A BA service delivery quality framework. From the ⁓ Silbaum Fital paper paper I mentioned, based on that definition of quality I gave, ⁓ you can look at that as a triad. There's professional standards, consumer standards, financial health. That's the aim. So the question I can only I really look through this through through through that lens. And so I say, Okay, given those conditions that you just described, to what extent are professional and consumer standards being attained in different ⁓ processes in the organization. So for example, like ⁓ you can an organization can set standards for what good looks like in a direct treatment session, a 97153, you know, in a reimbursed session. ⁓ But also they can set separate standards for what is a good protocol modification session, what is a good parent treatment guidance session. What does it look what does it look like when a clinical director is doing a good job in their clinic? ⁓ and so on and so forth. What does good recruitment look like? What does good scheduling look like? Right. So each of these are different processes, they have different standards. And and you know what? You could have ⁓ a service delivery system where you have a PhD ⁓ with 15 years of experience. They've published research. They're a master clinician and you have no standards. You have standards for protocol modification sessions and and they're unattainable because you keep Because you've designed, unfortunately, or there's the lack thereof of the design of the service delivery system or the process of protocol modification, or it can be scheduling, it can be staffing, it can be case assignment, where you've thrown competing contingencies at that master clinician that will not let them do their job. And that's a con I hear like maybe just 'cause I spend too much time on LinkedIn, but I hear a lot of time a lot of a lot of chatter about like master clinicians leave. not because they they haven't fallen it's not that they've fallen out of love of the work. They love the work. It's part of their life really if you're a clinician that long. I know as someone who's in clinical practice to some varying extent for 19 years it becomes a part of your life, you know, in a big way. ⁓ and so the love of the work doesn't go away. It's that you realize if you get so good at evaluating the co the you whether you're having a meaningful impact and your interventions are responsible for improving the client outcomes that you start to realize, I keep I'm I'm stuck in systems that won't let me that they they that system doesn't know that what it's forcing me to do doesn't work and actually squeezes out real ABA from protocol mod sessions and so and FBAs and the whole things. So I don't know. I went all down a rabbit hole but I said I was going to give you a framework and some heuristics, so let's go back to that, okay? speaker-2: Sounds good. speaker-0: So there's a pro ⁓ there's a professional standards, consumer standards, financial health. We'll call that ASDQ framework. Now there's ⁓ back in the eighties there was ⁓ a pioneer, quality pioneer, Joseph Duran, and I like to call him the Skinner of Quality to give behavior analysts an appreciation for like who he is in that field. Okay. So he's a skinner of quality. And he wrote a paper on something called the ⁓ quality trilogy or the Duran trilogy. I think the paper was like ⁓ ⁓ fundamental principles for managing for quality. I always forget. But ⁓ it was in the eighties and he was calling out American industries as ⁓ in need of ⁓ improvement in the quality of products and services. And his approach was, well, we have to completely transform what management looks like in American industries. And the way to do that ⁓ effectively is to apply principles of managing for quality That can be universally generally applicable anywhere, anytime by any manager in any industry, regardless of the product or service. ⁓ so if it's ⁓ yeah, so in the quality trilogy is quality planning, quality control ⁓ quality control, and quality improvement. And ⁓ that's the trilogy. And so you can ⁓ as an organization, if you're level one, two, three, four, five, doesn't matter, if you're the CEO, if you're a clinical director, if you're a technician. If you're an HR representative, doesn't matter who you are. If you are at work, you can plan for the quality of whatever work you're gonna do. You can control it by taking ⁓ so really quality planning means that you have ⁓ put in a plan for ⁓ what you or a process or a system or procedure will look like in operations and what the outcomes will be. Okay, so I can plan a protocol modification session and say in this three o'clock session in home with this client for two hours, I'm going to do visual analysis on skill acquisition and behavior reduction target. I'm going to assess fidelity on at least one skill acquisition target. I'm going to complete a part parastimus preference assessment I started in the last protocol mod session. I'm going to help that technician ⁓ prompt fade on a particular target. And I'm gonna check in with a parent on our next parent treatment guidance session and get that scheduled. I have a plan. That's the elements of my plan. So now I can go into my protocol mod session. And if I have my plan, presumably it's written out, not on my hand, it's written out on an Excel spreadsheet or in what Naskin has developed, the behavior analyst companion, which we could jump into, a tool that lets you do this. I can now self-monitor over the two-hour period, am I delivering am I implementing my plan? Okay. And then at the end of supervision, I can say, did I if I implemented the plan, I've engaged in quality control. If I said I was gonna do five things, I did those five things, then the outcome is the plan are the same. It's the same as if you get a recipe for a cake and you follow the recipe and you bake the cake, comes out as expected, quality control. That's a high quality cake. It's a high quality cake. Not because it met the plan, though. It's a high quality cake, or this is a high quality protocol modification session. Because the person eating the cake or the person who set out to bake the cake and has a personally defined standard for what that cake should look like, and the technician and the client who are the recipients of the planned actions from the protocol modification session, if they are satisfied with what just happened, now you have high quality. And so there I distinguish between quality control and the qualitative nature of quality. The qualitative nature, low, medium, high. Again, it's determined by the stakeholders, the consumers, the personally defined set of standard like standards attainment. Quality control is about did you implement your plan as intended? Quality improvement is you identify barriers. ⁓ you identify in fact when the plan is inadequate. Even though you're meeting the plan, there's waste in your process, there's waste in your procedure, there's errors that are made. So you take proactive steps going forward to eliminate that waste, eliminate those errors. That's quality improvement. So literally anybody can apply that trilogy anywhere, any time. speaker-1: Yeah, and that that that also touches on what you're like, let's double click on this. The the quality is everyone's job. It really puts that it shows what you mean by that, right? speaker-2: It's you know, I I find this very similar to the board ethic, right? And kind of going to ⁓ accreditation, right? Like you can follow somebody else's standard, ⁓ but that's different than you using your own ethic and and growing with that. Because you know, like the accreditation can get you so far, ⁓ the board ethic can get you so far, but if you don't have your own understanding of how you're going to put this in practice, ⁓ I think that, you know, we go back and forth. I see it on Facebook. That's not not ethical. Well, like I I you know, a all of these ⁓ little posts that I see on online, it's like I need a lot more information than that, you know, three sentence is this ethical or not, right? And ⁓ so I I think that that that is very similar to when you're starting your business, right? Does that make does that make sense? speaker-1: Yeah, I followed. ⁓ but I'm your wife, so I speaker-2: ⁓ and and then, you know, just going into KPI really briefly, because I I we could, you know, talk about any of these sections, and I'm sure that you do for hours and hours. When I'm coaching someone on starting KPI, like I I preface it with like this can be used against you very quickly, right? If you get lost in the numbers, ⁓ and and our complete focuses on okay, we have to be between, you know, X and X and Y. And that's that's how we know this is quality. Things can get manipulated and we get lost in that number and not in the actual intention behind what we're measuring. And ⁓ especially if you're providing incentives for these measures. ⁓ do you have any feedback on that? How to prevent that? Like an example that I all often use is like ⁓ skill acquisition. Right. Like you could have one B C B A that there like two B C BAs doing very similar tasks, and I am not a B C B A. So I'm gonna how I'm gonna say this probably terrible. But you have one B C B A that has like a goal and they broken it down into ten steps, ten skills. And then you have another B C B A that has broken this down into twenty five skills. Because they know the more skills that this child acquires, the more incentive I get at the end of the day, right? And so like ⁓ it it's just really important that we understand what we're measuring, right? Like ⁓ so that we don't have that unintended effect, right? The other thing that I have seen, and and then you guys can ⁓ take it where you wanna go, is You know, we again we're really we're wanting to make sure that we have a high level of skill acquisition. So we're going to during our intake process, we're going to maybe weed out some of the kids that we think, well, I don't know. I I I'm not sure I could get enough skill development here to meet my bonus this six months. So I'm gonna s recommend that we we refer this child out. Do you know what I mean? And ⁓ so that that's my concern when you start if you don't understand what can happen with KPI, that that these things could unintentionally just happen over time. speaker-0: I'm hearing that like, hey, okay, so l let's say you ⁓ in a given in this particular scenario, an organization wants to with the best of intentions, they want to improve clinical quality and outcomes for their patients or their clients. So they arrange a let's say a financial I'll just make this a financial contingency for the ⁓ for some measure of skill acquisition yeah, goals met per unit of time or or something like this, tied to number the the rate of skill acquisition as indicated by goal mastery or something in it. Okay. And so to your excellent point is that yeah, yeah, I can take a complex goal that would take three months to master and break it down into ten simpler goals that can be mastered at a higher rate. Or I can, I mean, literally someone can take a gross motor imitation goal where the child's to master, you know, ten different gross motor imitat actions imitated like Clap hands, arms up, arms out, touch, nose, touch, tummy, stomp feet, and all these things. Literally to treat each one as a goal. And you know, and so I actually I'm I'm used to treating that whole thing as a goal. Okay, you gotta meet ten targets and then a goal's met. But if there isn't and there isn't, there isn't standardization in the field of how that's done. And so that explains there's variability in in that KPI, if you will, to th those like ways to gain this I don't know, gaming this is the right way to say it, but it's just like different ways to approach the problem of increasing the rate of goals mastered, that metric. Right. Yeah. Which is I think that's what your point was like it's it's not getting the point. Like this isn't about that number. It's about is that child's repertoire increasing faster to be benefiting. Yeah. speaker-2: Do they have a better quality of life, right? Like like you know. speaker-0: Okay, so here's the deal. I'll I approach this in a way that I think is unconventional. I think it goes against the grain, probably. And ⁓ and I'll say this, I'll say ⁓ that ⁓ I think it's probably focusing on number of goals mastered, even number of skills mastered, is is totally a distraction. It's missing the mark. It's missing the mark because ⁓ I'll say it this way, what gets measured. I think I've said this before. What's gett what gets measured gets selected. And so and then so but I I learned this from Jose Martinez Diaz, who was a really in s an inspiration to me and a mentor at FIT, ⁓ who has since passed away. And ⁓ in one of his lectures he talked about you gotta be really careful with permanent product as a measure. Like if You're measuring aggression in terms or no, let's just say you're measuring property destruction as the occurrence of new crayon markings on the wall or something like that. Well, you if there's more than one kid in the house, you don't know who marked that wall kind of thing. Okay. And then ⁓ and you don't know the circumstance, you don't know the behavior. And so you want to be careful if you are going to measure results of behavior and tie contingencies to it, you have to be very careful of unwanted ⁓ effects on behavior that produces the result. Or we just kind thing. So here's a thought, okay, is this is ⁓ and I'll tie this to like CPT codes, nine seven one five five, for example. You know, or it doesn't matter. CPT codes, ABA companies who are have insurance contracts getting reimbursed by Medicaid, we're we're billing by units of time, fifteen minutes at a time, right? And so the contingency there influences everything that practitioners do. It's going to influence the PPIs that the organization selects and so forth. And so really what behavior analysts get paid for is time with patience. You take that contingency real literally. And then there's the hope that what happens during that time is the evidence-based pack evidence-based practice of ABA with outcomes that are planned. That the planned speaker-2: Mm. speaker-0: outcomes that are happening during protocol mod or drug treatment sessions are the actual outcomes that happen. Sometimes this of ⁓ focus on outcomes, really foc like this conversation on outcomes, and ABUs focus on every six months is a reassessment of norm references, standardized ⁓ assessments, and you want to see differences between the administrations, the results of those administrations, well that outcome is like, way, it's gone. Like the whole six months is gone once you assess that. And a focus on those outcomes and you that might even be the time where an organization looks at okay, how many goals were mastered in that care cycle or service period? I gotta say, I really feel like it's irrelevant because what really matters is the point of contact of care during each 15 minute unit, and really it's like hour, two hour, three hour supervision sessions or direct treatment sessions. What is happening in the interaction between the practitioner and the client or the consumer? What's happening? What what is the exchange of reinforcement between them? How often does that happen? And what are the results in terms of the client's behavior ⁓ as a result of the exchange of reinforcement between therapist, if you will, or technician and the client? And so that's why I say that KPI isn't meaningful. I said what's a meaningful KPI is if is what was planned for the session to happen in the session, not cumulatively six months later. Now they're with you now and they need you now. We need an outcome now. You don't go to the dentist. You know, when you go to the dentist to get a root canal, you get the root canal and then you go home, or you get the whatever, the cavity filling, and you don't and you go home, right? Because there's an outcome that is expected as a result of that healthcare practice they're engaging in during that time with you in the chair. Well, similarly in ABA, we have to f I believe it from a quality assurance perspective to systematically improve. quality over time and f with a focus on outcomes, you got to get at the point of contact of care right there and measure what did the behavior analyst do in the last five or ten minutes that resulted in an improvement in antecedent stimulus control over the client's behavior or response differentiation enabled them to say a new word? What happened now? Right now that they enabled that. Okay. What what enabled now for them to go longer? Without engaging in SIB so that they could participate in a few more skill acquisition trials. ⁓ Did you plan to engage in a preference assessment to identify a re a preferred stimulus? And as a result of that process, that supervision process during your protocol mod session, did you identify a preferred stimulus? That outcome has a great deal of value to the client. They don't know it yet, but it does. Because if you have a preferred stimulus for that client individualized to them, now you can do a reinforcer assessment and test, does that does that produce learning now? Not over three weeks, four weeks, cumulative. No, no, no. Now. Does it work now? You know? So I know I'm emphasizing that maybe a little dramatically. ⁓ but if I think if you have KPIs that are tied to outcomes at the point of contact of care, you don't need a quality assurance system. Wrapped around your whole organization to deliver high quality services, you can start right there. speaker-1: that I love that so much. Going back to going back to the quality is everyone's job too. Like we've had conversations on here before with other leaders in the field talking about ⁓ understanding your own like i is self self awareness and self assessment ⁓ as a behavior analyst, as a clinician, as a tech, you know. speaker-2: I completely agree with you that that would be but how how do you put that in practice? So let's okay, so BCBA says I've done the assessment on this child, right? And I have a plan ⁓ of how I'm going to train my staff, right? Like ha how often we're going out there. Right. But yeah, so like how how often cause I like how often am I readjusting my expected outcome in my session, how often should my RBT also be reevaluating? How do I even put that into practice in my company, right? Because like you said, I'm trying to survive here, right? And that sounds like a lot. That sounds like a so how would you how would you do that? I'm curious. speaker-0: Post, gosh, it ain't as hard as it sounds. And it ain't okay. All right. And I'll prep I'll try to s give you a simplified model of how anyone anywhere can get started this right after this podcast, after listening to this. Okay. And I I want to touch just briefly on what I think April was was going with. And correct me if I'm wrong, but I or I think April, you are starting to get sort of in the area or wheelhouse of being sensitive to or being mindful as an employee that Everyone around you is a customer and you're t it's their service and they have different perspectives on your performance, what you're delivering, and what good looks like. And that's there's a malou there. You gotta i i so that's important for delivering high quality services is is knowing that like the client has an expectation, the supervisor has an expectation, the director has an expectation, the parent, they're all your customers and you're delivering a service when you're in the room running discrete trials or PRT or incidental teaching chain and all things. ⁓ But ⁓ so I don't know if I touched on that, but speaker-1: Yeah, yeah, for sure. Yeah, you kinda help bring that together. Yeah, right. Just kind of looking at ⁓ the the the bigger picture and how things are working together with that perspective. speaker-0: It's if you're at the bottom of the ladder or the bottom of the organization, you really can't see a whole lot past what you're doing in the day-to-day in your direct treatment sessions and that can be hard to look beyond. ⁓ but to your question, ⁓ Stephen, about like, okay, so how do we simpli let's simplify some of this complexity of what Brian just said in like h or like any of this and how do we put something into action, you know? So ⁓ it's an excellent question. So I I would suggest audiences or listeners think about this as Establishing a self-management practice. It's as a clinician, how are you going to manage what you do? And your vital few. Let's call it your vital few. Every day you wake up, you go to work, you've got a thousand things to do. Well, no, you don't forget that. You've got to narrow down your day down to a vital few. Okay. And that's the way everyone deals with complexity. And you realize that as you get older and you fail more. And ⁓ y you have some successes and then you realize, ⁓ my gosh, like I really don't do anything. ⁓ if I do anything in the day as a successful person in a career, I can do two or three good things a day if I want to. You know what I'm saying? speaker-1: So a value. speaker-0: Like I'm getting old now, I feel so anyways, that's where that comes from. But yeah, a vital few, okay. And so it's like I'm gonna go into su today I'm gonna do protocol mod sessions on my cases. And I'm not gonna do all the things. They all have like forty programs, whatever, and I've got eight to twelve clients or whatever. No, no, no, no. You're gonna see a couple clients today. A vital few can be like I'm going to systematically self manage myself. That's a vital few. I've gotta do it. To deal with the complexity and the competing contingencies and the stress and the pressure and all the things going on in your life, you have to have a plan to self manage and accomplish two other things. So one is I'm going to deliver a meaningful outcome to my clients and the clients that I see today and the technicians working with them or the parents that I'm going to be coaching today. One meaningful outcome. Don't get crazy with it and overdo it. It's one meaningful outcome, but very specifically that you can T direct ca ⁓ tied to your interventions or your assessments, causal evidence, irrefutable, objective verifiable evidence that you did something that produced an outcome that someone else wanted and expected as a result of part receiving ABA services. ⁓ and then I would say the other vital the third vital feel is you better celebrate at the end of the day. Right. Okay. You take all that. BS that you have to stru deal with all day to get your two things right today. And then you can still breathe and walk at the end of the day. You better celebrate ⁓ that you got through it, you know. ⁓ so that's important. So say plan have a self-management plan, plan to deliver a meaningful outcome from your stakeholder's perspective for each person you're gonna serve that day, and then celebrate it. So then the next question will probably be like, Okay, what does self-management look like? Well the cool thing is it is that ⁓ I think technology is a major answer to how do you do that. And old school would have been like, Bring a notepad. That's twenty years ago, okay, and write your plan down in your notes and then keep track of your progress rather than your notepad. That's old school. Then we have technology, Excel spreadsheets or whatever, right? Okay. And now I think the next generation of tools for practitioners of ABA to self-manage and monitor, deliver, improve their outcomes that they're providing others over time are apps. You need something in your hand because that freaking phone is glued to you for the rest of your life. It's always with you. Okay. You're very good at going boop, boop, boop, boop, boop, boop, boop, and navigating to things and apps are user are made to be user-friendly now. So at NASCAIN we've developed the behavior analyst companion app and it's meant to do exactly this. It's extremely simple. Where it enables you to monitor your stress, to check in with yourself, to maybe take one action a day to care for yourself, whatever that may be, as defined by you. ⁓ And then to ⁓ get gain insight into other users of the app. How are they feeling about particular aspects of the experience of being a behavior analyst? And then also to s to celebrate. So in the app. It's like this. It's 30 seconds. You open it up. It's free, by the way. In the beginning of the day, you can open the app and it's going to ask you to rate from one to five your stress ⁓ and your ⁓ energy and your caseload or workload pressure, depending if you're a clinician or not a clinician. And boop boop boop takes 10 seconds. And it's going to populate and show you a graph over time, days, weeks, months, quarters, of how your stress and your caseload pressure, workload pressure has been varying over time. And if it starts to dip, Or trend in the negative direction, you'll get prompts on the app and it'll give you self ⁓ give you ⁓ suggestions for how you might take a moment. Like for example, put your devices down and for 30 seconds, close your eyes and think about one big reason why you got into this field and why you're doing this work and reconnect with your passion. What meant everything to you and why you're doing this. ⁓ now the cool thing about this, I don't know if people are using the app that way, but that's my vision is After you reflect, you track on the app and you say, Yep, I did it. And then you go to your wins. And that's where you should visit. At the end of the day, you reflect on wins. What did I accomplish today? I should log one or two. So I celebrate. Because I've you got to keep just like with our clients, if it takes three months for a kid to learn how to match 3D identical objects, ⁓ and you can attribute it to that intervention, dude, those three months were hard, but you're freaking floored. when they can freaking match independently. And you're like, hallelujah. We have a breakthrough. And now we can do more. And it was all freaking worth it, right? So we're already conditioned to celebrate small wins for others. So I think an app like this can help you celebrate small wins for yourself. You need to focus on you are accomplishing your vital few. And then the last step of it is like there's a supervision feature. In the supervision feature you literally can click a button says plan session. And then you can check boxes that say, I'm gonna do FA today, I'm gonna do fidelity assessment, I'm gonna write do protocol, I'm gonna write a new protocol, I'm gonna do protocol mod, I'm gonna do this, I'm gonna train the staff. Click 90 minute session, click start. There's no client identifying information, it's private, it's yours. Okay. And then you start your session and there's your self-monitoring thing. You just check the boxes as you deliver the outcomes from those processes. Click another button, you get a graph that shows you the percentage of your planned outcomes that you've been delivering over time, and now you can track it. Even better, down below, there's something we call a supervision value calculator. In value-based care, the basic formula is outcomes over cost, right? It's like what can you deliver to your patient over the unit of time in the care cycle? That equals value. So we just converted that to a protocol mod session and we look at the Point of contact of care, the outcomes that you're delivering, and right there for your client using evidence-based ABA, how many are you delivering in the amount of time that you're supervising? There's the value. And so that's data that you can use to then self-manage and improve over time. And that I think that's an easy way to start. You don't have to be all sophisticated. You can say, I'm gonna plan one thing, you know. By law, but I mean, or in order to do a protocol mod session, you got a protocol mod. So click that button. Start speaker-1: ⁓ I love that so much. And I think that that that ⁓ I know this sounds goofy, but like kind of made my brain happy because this self management practice, like the the the vital few and like pulling it together, it really helped like what where I was trying to go with okay, well we're all like we're all responsible, right? We all have ⁓ can some control over like quality. Each person ⁓ yet there's this level of like ownership and like self ⁓ like ⁓ self ⁓ understanding ourself and being self awareness, you know, that piece, right? And so and then Steven's like, Okay, well what's the next small step? Well, it just all brought it all together. I love that. I'm so excited about this app and and even just the way of looking at it, just a self management practice of how to go in looking at it and helping because also I think it's important too, even a part of this as important as the planning piece too. Because I know that's one thing that we can get really swept up and life gets busy and and we pop into a session and then we're like, okay, where are we doing? Who's who you know? And and and then you spend a bit of time either either listening to the tech, like asking questions or saying, here's the problems or, you know, the parents, you know, talking and then, you know, you get halfway through the session and then you're there then you're trying to figure out, okay, what do I even need to do during the session? speaker-2: What? Getting texts on your phone from another crisis that's going on, right? Like speaker-1: So really just being able to help slow down and be mindful in the moment of even if it just takes a even if you just spend a few minutes, but making sure that you are taking that moment to prepare for the session that you're going into or the the service that you're about to provide, I think is also a very helpful part of that process. speaker-0: It in my ⁓ in my book on quality control in the introduction there, I share that like I was in ten years practice, you guys, clinical practice, where I didn't routinely assess fidelity or IOA. And so I just made assumptions about the data that I was making database decisions about, you know. And of course I watched my technicians run the programs and made decisions in the moment based on am I seeing them implement something that looks like, yeah, that looks right, you know, like I have my own I have a way of controlling quality, so to speak. When I came out of academia, having been trained so much in single subject design and having a research program and getting really, really good at noticing when s my decisions, my interventions, my protocols that I write, are they are is it true? Is it true that they're responsible for for my clients meeting their goals or making progress or behavior change? Is that real? You know, and how good can you get out of a lab and into the real world and communities, homes, grocery stores, libraries, parks and families, homes and daycare centers at controlling enough of the therapeutic environment where you can ⁓ capture causal evidence with single subject design and using Fidelia and IOA to causal evidence that your intervention really is having that effect in the real world because there's it's hard to put scientific methods into the real world with real people. know? And so at some when I went back to practice after being a professor, there's a lot of variability in the graphs and I was like, here's the deal. I gotta say goodbye. I am either going to quit and never ever be in a clinical role again, or I'm gonna figure out how to routinely assess fidelity in IOA in every single session, anywhere, any time, any system, any process, in any capacity with any client who I'm responsible for doing like providing ABA. I've got to figure out how to do it because system imperfections and systems are absolutely everywhere. You cannot get away from it. You must accept that you work in imperfect imperfect environments and systems. And you may even get lucky and score and get in an organization that is investing everything they can into improving their systems and relevant and appropriate KPIs and monitoring systems and feedback loops and standards and all the things. And they might even like practically be going broke because they're spending so much time trying to improve the conditions, you know? And even there, there's gonna be barriers. So you better figure out how to do this or do ABA everywhere, anywhere, anytime. That's was my mindset. And I was like, if I can't, I'm out. I don't wanna do I don't wanna I don't wanna waste people's time. I don't wanna live a lie and and like report on treatment outcomes that are bogus or that I haven't even I haven't personally verified with a certain level of my personally defined standard. Whether I was responsible for that, or if that just happened and I got lucky as a practitioner and now I get to s look great that my client improved over six months, that's wrong. You know, I feel strongly about that. speaker-1: So okay. So when we're talking about that self management practice, let's say and we're looking at okay, so we're t we're talking about B C B A and the traditional sense, the two tier model, they're, you know, supervising an R V T and, you know, doing all the clinical ⁓ work for for the for the learner. But but what and so I think in those roles, even if you come into a job with maybe ⁓ poor expect communication of expectations. you you at least somewhat know what's expected of you of an a B C B A. It might not be a a full encompassing or a great expectation, but you have general idea of the main pieces that you need to do, right? But what what about it maybe even a tech too? But what about other the leadership of the company, you know, the clinical director, the, you know, managers and HR and billing department and all the other people that make up an ABA agency, right? ⁓ something that that we we see actually quite a lot is Azure. Okay, so you start as like a a single B C B A small company, right? And Steven already spoke to it little bit earlier. And then like you're in that level one and and then you find yourself still in that level one three and four years in and you've grown really fast and things are out of control, right? And in that process You've hired, okay, okay, fine. I have to delegate. I'll hire you to do this. I'll hire you to do this. I'll hire you to do this. And then finally it comes to the point where you realize, okay, things aren't things are really messy here. And and so the meat of this is like not having clear expectations. Not having clear expectations for the BCBA, for the RBTs, yes, but also all of the other roles within the company. Like, help me connect that importance of having those clear expectations to being able to to do the self-management practice and to be able to be responsible for quality within your role. speaker-0: think ⁓ I I hear expectations and think standards because it exp if someone if someone if you if someone has an expectation of your performance, they've defined what good looks like. And they're presumably ⁓ and then so the question here becomes how do you engage in practices where your performance meets their standard, meets their expectations. So I and I say that because the If you equate standards with expectations, that gets you right back into the ASDQ framework and ⁓ and and stuff, you know, of trying to ⁓ yeah, so I would say yeah, I don't know if I'm if I'm answering your your your question here, I might lose it, but ⁓ but I but I would say like ⁓ if you're a ⁓ let's see if we get this right. It's like if you're at a if you're a level one or a level two, so to for audiences or mind or level one is like ⁓ You're a very small practice, you're a startup, maybe you're one or two years into it or something. ⁓ there's in a clear definition of quality in your organization, supervision practices very widely. ⁓ decisions are based on perception. You're starting to make database decisions, you're starting to do that better. But what you probably realize is that ⁓ you haven't been monitoring and your data aren't what you thought they were, or maybe your data aren't as valid, accurate, reliable, or cost efficient, and then it's hard to make database decisions. ⁓ I think this will lead us into another triad. Okay, we didn't get to this before, but there's another there's a framework that helps maybe contextualize and help us think about your question, which is ⁓ a quality assurance, ⁓ a model of quality assurance in human service settings that was ⁓ developed by ⁓ or from chapter two in the book by Bradley and Bersani. ⁓ do I have the book around here or remember the title? I don't, but we'll put them in the show notes, I suppose. Okay. So we'll put them in the show notes. And ⁓ their triad is ⁓ standards, monitoring, and response mechanisms. So ⁓ if planning, control, and or let's say stand ⁓ professional consumer standards and financial health are a br a big old like umbrella framework within which to pursue quality assurance and build quality assurance systems. Planning, control, and improvement are the principles you apply to attain standards in that framework. ⁓ the same way we apply principles of reinforcement and punishment ⁓ to establish behavior change. Well, you have a desired goal, right? You have a standard for what that behavior should look like. And so you're it's the same idea here. Okay, so you apply principles of planning, control, and improvement. And now ⁓ that's the Like think of it as the engine. Now I think when we talk more about standards and meeting expectations, we should talk now about the what or sorry, the how of quality, which is standards monitoring response mechanisms. So your standards again specify how well your how what good looks like. And so you can specify that for any role, any responsibilities, any organization. But then you have to have monitoring systems in place that measure indicators of whether those standards are attained. ⁓ and then ⁓ but not all standards are the same. So there the Bradley and Brasani, and I wish I had this stuff memorized, but I don't, but people who go to that chapter two, you know, will see Bradley and Brasani define like five or six indicators of a suitable standard. An example can be is a standard ⁓ clear enough that any can anyone can read it and understand it? That means engage in behaviors that are specified by the standard. Maybe another criterion is a standard ⁓ flexible enough to that it allows an organization and its employees to deviate from the standard when it's appropriate and necessary, because sometimes it is. And then so if that framework provides someone a list of criteria to evaluate are standards suitable for what we're trying to accomplish? And then the monitoring is is about are your data ⁓ are you s are you spending is qu ⁓ you should ask questions like are you spending too much money to collect data on the practices that related to the standard? Like are you investing too much time or labor to justify the results or the the dis the the the decisions you're able to make in practice to improve performance? ⁓ another one is is it val is measurement valid? Is it reliable? Can it be automated? But right now it isn't. ⁓ do you have in our observer agreement on data collected in a monitoring system? Now, if your standards are re are suitable and your monitoring system is valid, reliable, accurate, cost efficient, predictable, now you have the right data and you can start making decisions and feedback loops. You have response mechanisms, contingencies to improve performance. And so that's where I go when I think about s something expectations. I think it's really ⁓ It's tough to expect people to meet your expectations if as a leader you haven't yet designed a system with valid stand ⁓ suitable standards, valid monitoring systems and feedback loops that gives the right information to the right people at the right time to allow an adjustment that's meaningful. speaker-2: The probably the main expectation of a BCBA ⁓ for many practices is you get your twenty to twenty-five billable hours a week, right? Like that that's it. Do you know what I mean? It's not anything on quality of life. It's not anything on, you know, it it's just I need you to make this amount of money so that I can financially continue ⁓ to grow this company and it's you know, a certain level of profit, right? And ⁓ because I I know when I talk to many B C B, it's like ⁓ like the only focus is on billable hours, right? And that is the only expectation is you know, so and and so like I I think that goes back to the meaningful outcome, right? Where where you you where you were talking earlier, like do you feel that that's a skill that most B C BAs have that they can measure an effective outcome? Does that come natural to most B C BAs or is that speaker-1: But it doesn't have to be speaker-2: A gap in training speaker-0: Maybe the average or the maybe b ⁓ every behavior analyst should have someone helping them ask that and answer that question. Like you know, and that's no new advice. It's like have mentors and supervise and friends and colleagues and and be vulnerable and be open about your practice and the decisions you make in your thinking and let people give you feedback on it to tie back to what you were saying earlier, April, ⁓ so that you can discover that. speaker-2: Yeah. speaker-0: You know, because there's gonna be anything's variable, right? Like there are probably like plumbers who like can't evaluate how good they are of course like doing their job or whatever, you know? And so it's I would say absolutely not. That wouldn't come naturally to any or most people probably, and therefore it's helpful to do ⁓ but you know what? If your beh behavior analysts are trained to do things like task analyses, comp posit component analyses to observe others and their own behavior and and break it down. Break it down into measurable chunks, you know, and so like if self-management doesn't come easy or come natural, or even it's even monitoring, even if it's hard to say, I'm gonna go into my protocol mod session today and I'm going to do one protocol mod, and I'm gonna assess IOA on any challenge and behavior that occurs. I'm gonna answer the technician any questions they have and try to eliminate barriers for them. And I'm gonna do my soap note before the end of the session. ⁓ even so much can happen, especially in ⁓ in home, I would say. That the person it doesn't come natural to everyone to even be able to remember, wait a minute, I'm supposed to be mo looking at that list I planned and I'm supposed to click boxes or check things. Right. You know? And so what I would say, I love this. saying of eat an elephant one bite at a time. It's like, okay. It's like anything that feels overwhelming or you're underprepared and you know that. And is to that's where the vital few concept comes in that I think is helpful to folks regardless of their career. I even apply that to my, you know, my role as a dad, other identities I have, a dad and a And a husband and all a community member and all these things, I think, I can only do a few things well. But so let's make sure I I focus on those, you know. And maybe one of your vital few is to ⁓ you know, if you're a new B C B A trying to self-manage and you're noticing that you're having trouble with that, your vital few is to reach out to somebody who can help you, you know, and be maybe your vital few is be vulnerable and be open. Show who you are and what you got. And what you're about. Don't hide nothing. Maybe that's your vital fuse. Don't hide. speaker-1: Yeah. speaker-2: Yeah, even yeah, yeah. speaker-0: Will be surprised how people will embrace you and take care of you and help you. speaker-1: Yes. If if you don't if you did not take anything else from this conversation, that's the piece that that that's the piece that please walk away with, right? Because it really is it's we're all human and I've s I say this all the time, right? Like that that we really truly are human and we're humans working in a human field. And there are so many variables and we're bringing with us like our whole selves too. And ever so are everyone that we're working with and the families that we're working with and the individuals that we're providing services for. You know, it's it there there's there's a lot there's a lot going on here when you're in a a human service field, right? ⁓ and and so so yes, yes, you know, be open, be vulnerable, be curious, right? ⁓ absolutely. speaker-2: And so the app you is that that for B C B A's just like doing their own thing, is that w what you would recommend for them? speaker-0: I think it's an excellent starting point. You know, the tool won't be useful or like reinforcing to everybody, you know. I mean anyone can pick up a notepad and plan and monitor the outcomes of their session. ⁓ and so but ⁓ we're all ⁓ we all use apps readily and ⁓ they have a strong influence on our behavior and if you need you know, w we've also designed this app with ⁓ notification settings. And so that it might help too. It's like ⁓ Your notepad and your Excel file are not gonna notify you, okay? But if you have an app that you can s click settings like ours, then in the beginning of your day or before a session, you can plan it and then you implement the session. At the end you'll get an you can set it up to get a notification at the end of the day. It says, Hey, you had planned some outcomes. Don't forget to ⁓ track them today and then track your win too. Because I don't know you guys. I can't live my life without technology or reminding me of very important things, you know, like I have ⁓ going to a personal trainer tomorrow 'cause I can't keep my butt in the gym and my body's getting old. And so hallelujah, they have a system that just texted me, you know, an hour ago says, Do you know you have it remember your appointment tomorrow? Right. Great. What am I? A wizard? I can't keep track of everything. So so I'd say rely on the app. Don't go caveman style and like make markings on a wall or no, use technology. I know you got a thousand apps on your phone, a thousand systems you navigate, but this isn't the world. This is the world today. So we have to adapt to Yeah. speaker-1: Yeah for sure. speaker-2: And then organizations like if they're like, Okay, I wanna implement a quality system, I wanna do it well, this is important, I can see that, how do they like what would be the point of contact to reach out to you? Where where would the starting point be ⁓ so that they can start this journey? Yeah. speaker-0: any organization wants to learn more about, you know, what NASCAN has to offer and how to help organizations or individual ⁓ practitioners, because we are a a professional association. So w our mission is focus on ⁓ A BA professionals in general. Guess what? The leaders at the top of organizations are A B professionals, right? Okay. So ⁓ but ⁓ I would say the best way to reach out to us is ⁓ to email me at bsilbah at naskin.org. I'm sure that'll be in the notes. ⁓ Naskin's, you know, website. ⁓ we have a contact form there as well. ⁓ subscribing to our newsletter, and ⁓ following myself or Naskin's ⁓ LinkedIn page. ⁓ I think those are really great ways to stay connected and reach out to us. ⁓ we have other, you know, ⁓ ways to help ⁓ ABA professionals we haven't talked about today. and also we learn. So the more that people reach out from us and tell us, you know, what do you where are you at in your journey in ⁓ expanding on your prof you know, your your repertoire, your prof your quality assurance repertoire? How's your professional development within the domain of quality assurance? Quality plan, quality control, quality improvement, quality ⁓ have you considered maybe ⁓ getting a certification in Lean Six Sigma where you can learn a whole set of ⁓ quality methodologies outside the field. ⁓ How do you do that? Who do you go to? Who's got it? Who knows about that? Well, we have people who know about that. ⁓ we've got a member of our executive team who's ⁓ Lean Six Sigma certified. And ⁓ and so anyway, so so yeah, we learn and ⁓ NASCIN was designed to promote a more empirical approach to quality assurance throughout the ABA industry to sort of address what I think, you know, is a turning point in the field. And you know, any like I was I was saying, like, I don't know, discipline or service or field or whatever. Just like organizations, just like people, they develop, they evolve, they grow, they mature, and we're in we're in our infancy in terms of a feel like the practice of ABA, you know. And I think that's where we're at. We're at a turning point where it's time that we should we ship and that's gonna we believe it's time that we really shift from a focus on access. to a focus on what people are getting access to. Right. ⁓ it's the access to high quality services because access alone is really short. That's not actually what anybody needed. They need access to services that work. speaker-2: No. Yeah, yeah. Access to terrible services is not helping anyone. Yeah, I and then I I think you all have a job website too, right? speaker-0: Yeah, we have a career center and the vision for the career center is that it connects ⁓ A B professionals who are really passionate about quality. Maybe they're pursuing ⁓ Lean Six Sigma certification, like trying to expand on their ⁓ professional development ⁓ repertoire in quality assurance. they're members of NASCAR, ⁓ folks who ⁓ wanna find ⁓ employers. ⁓ who are building systems and processes and have standards in place who are ⁓ maybe and it's it's it was really about like trying to connect ⁓ job seekers with employers on quality at the right stage for both of them. Okay. So it's like, you know, someone who's really skilled ⁓ in quality assurance in ABA, they might get real excited about connecting with a level one or a level two organization to help lift them up. ⁓ and help them take leaps ahead in what they're doing. And then but there also maybe behavior analysts who really want to land in a level four or a level five, you know? And and so all of that isn't really like clear or built out in the career center. That's more like the long-term vision is make that a trusted s source or hub where people who are ⁓ job seekers and employers who are really focused on quality connect and I I believe I believe that ⁓ it's safe to say that most of the people who go to that career center are job seekers who are focused on quality and therefore that's different than posting on a different career center or job board where you're gonna get a wide variability and who's looking at your job descriptions and postings. So thank you, Steve, for asking about that. ⁓ speaker-2: Yeah, I think it's important, right? Because if we can it like you we're kinda pointing the people in the right direction, right? And so if there's if if company leaders have incentives to go and find a quality ⁓ person, right, they know that okay, if I go here, I'm going to get who I need for this role. I I think that that that will be helpful to everybody. So yeah, I I love that idea. ⁓ I I think it and you know, as the the owners of the company go through this, it may even ask them, it may even elicit some questions. ⁓ I didn't even think about that. Let's ⁓ let's have a further conversation on that. Right. And so yeah, I I would urge everyone to, you know, at least go to your website, but try out the app, go to the job website if quality is important to you. I I yeah, I think that's great. So speaker-0: Thank so much. speaker-1: ⁓ my goodness. I got so much out of this conversation today. I'm so excited. ⁓ I could definitely continue talking for for longer. I have many more questions in my head. I don't know. Maybe if we're lucky, maybe Bryant will come back on another day to continue the conversation. ⁓ great, great. ⁓ so all of the all of the links, all of the the things that we talked about today are in the the show notes though. I if we don't already, we'll make sure to get the ⁓ speaker-0: All two. speaker-1: how to access the app ⁓ and put that in the notes as well. Thank you. Thank you for such a great conversation today, Bryant. I really appreciate it. speaker-0: Thank both. Pleasure being with you and ⁓ yeah, I hope we can do it again. This was awesome. speaker-1: All right, guys. Those of you who are listening, thanks for thanks for being here today and we look forward to seeing you next week. speaker-2: See ya. Welcome to ABA Business Leaders, brought to you by 3 Pi Squares, where we discuss topics on how to create and grow an ethical and sustainable ABA practice. speaker-1: Whether you're starting, scaling, or thinking about selling your business, we're here to share insights, stories, and strategies to help you on the journey. speaker-2: We owned a successful ABA practice for over ten years. speaker-1: And now we help other ABA business owners do the same without all the chaos. speaker-2: Stick around, you're in the right place.