Incentivizing Quality, Not Quantity: A Call for Holistic Incentives in ABA Therapy
A few months ago I wrote an article about the need to develop the “science of ABA service delivery”. What prompted this article was a rudimentary observation regarding ABA organizations across the board, and what they value when delivering ABA services.
To really figure out what an ABA organization values, you needn’t look any farther than what the organization chooses to incentivize—their Key Performance Indicators (KPIs). KPIs are fancy business terms for “behaviors we value and want to reinforce as an organization”. Most companies will offer incentives to their employees for meeting these KPIs or valued behaviors.
It’s not always the case, but throughout my experience in recent years in working with larger, growth oriented organizations, the KPIs are pretty simple and are geared toward their center based leadership personnel: center managers, clinical directors, regional managers, etc. And, they seem to revolve around three key areas:
Billable hours. BCBAs, centers, or regions may be offered bonuses for hitting a certain number of billable hours.
Rate of onboarding clients. Center and regional leadership may be offered bonuses for the number of new ABA clients that begin services with the organization.
Labor utilization. Center and regional leadership may receive bonuses for keeping the number of non-billable staff at a minimum.
Now, there are a lot of clinicians out there that will immediately balk at these incentives. It’s all about money… right?
Well, it’s a little more nuanced than that. Certain behaviors are necessary for keeping the doors open so that clinicians can help kids. Thus, a little extra incentive for center leadership to engage in just makes sense. It’s a fact that in the ABA world, it’s quite hard for an organization to survive if they aren’t billing insurance regularly and gaining new clients to some degree.
Incentivizing the “bottom line” behaviors in these areas isn’t the problem.
The real problem is two-fold…
First, the standards that are set for these “bottom line” behaviors are too high/tight/ extensive/ridiculous.
Such as, incentives for billing too many consultation hours. This results in massive caseload sizes in which kids are unsupported (and perhaps, unprotected). Or, incentives for onboarding large numbers of new clients, forcing organizations to onboard cohorts of undertrained, under-qualified, new hire classes. Or, incentives for sending home all (or almost all) non-billable staff each day so remaining working staff go without breaks, lunches, bathroom breaks, behavioral support, and ultimately leaves the vulnerable kiddos more vulnerable.
Second—and the other problem—some organizations tend to ONLY incentivize these “bottom line” behaviors and don’t look to incentivize clinical, relational, professional, and ethical behavior.
Ever wonder why that BCBA you work with—who is a rude basket case—keeps their job? Well, this might be why. They’re probably hitting their KPIs—but they aren’t incentivized to do the things that make a BCBA a good BCBA. Clinicians tend to turn away from the clinical, relational, professional, and ethical if they’re incentivized to do so. In fact, it may lead them to be completely insensitive to those measures. And again, it puts the vulnerable kiddo in an even more vulnerable spot.
And, this is the real and most deeply disturbing problem, isn’t it? It leaves a vulnerable population more vulnerable with services than without.
Not good.
So with all that in mind, it behooves us to KNOW with increasing specificity what the behaviors are that indicate quality services are being delivered on a clinical, relational, professional, and ethical level. So my questions to you—my dear readers—are as follows: Which clinical behaviors (specifically) do YOU think indicate quality performance for a BCBA in these important areas? And what is your organization (or past organization) doing to promote quality services in these areas, if at all?
Let me know!
Happy Friday!
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