As a BCBA working with different ABA therapy practices, I often see leaders stuck in what Robbie El Fattal calls the “tyranny of or”, thinking they must choose between improving clinical work and outcomes or keeping finances strong. Dr. El Fattal recently presented on this topic at the FABA conference in Orlando, FL, asking if leaders feel they have to pick between focusing on clinical work or running their business well.
I see many organizations presented with this false choice. Leaders worry that dedicating resources to elevate standards of care will undermine profitability and threaten sustainability. However, with the right quality metrics and systems thinking, organizations can transform clinical outcomes and fuel financial growth together.
Defining Organizational Quality in ABA
First, we must define quality at the organizational level. Silbaugh & El Fattal (2021) recently proposed that ABA service delivery quality (ASDQ) means meeting professional standards and consumer expectations consistently over time – while sustaining financial health to fulfill an organization’s mission. This defines high quality ABA as balancing upholding evidence-based best practices and meeting patient and family needs with the financial ability to deliver excellent care long-term.
Interconnecting Clinical and Operational Outcomes
Delivering high-quality ABA requires understanding the interconnection of all organizational systems. Improving family satisfaction requires recruiting and retaining talented staff. Retaining top talent necessitates competitive pay and career development opportunities.
Funding these priorities demands smart financial planning and revenue growth. Within a complex organization, a change in any one area affects the whole.
Where there is no margin, there is no mission.
Mission Depends on Margin
A common phrase by Irene Kraus applies to values-driven ABA providers: “Where there is no margin, there is no mission.”
Generating surpluses enables investment to:
- enhance programs
- expand access to care
- retain exceptional staff to support more individuals and families.
However, leaders must avoid over-prioritizing profits without accountability—quality and ethics cannot be compromised.
Measuring What Matters
True organizational quality requires quantifying key indicators demonstrating both/and thinking is effective. SMART Key Performance Indicators (KPIs) can be directly tied to quality metrics. For example, “Increase annual net revenue 20% over two years by maintaining customer satisfaction over 90%.” Metrics like turnover, net promoter, parent surveys, and outcomes can help you track progress toward such goals.
SMART KPIs
- Specific: define what each KPI is intended to measure, and why it is important
- Measurable: KPIs should include standards for measurement
- Achievable: the KPI should be a realistic, achievable goal
- Relevant: KPIs are intended to move a business forward, so they need to be relevant to improving outcomes
- Time-bound: it’s important to set a realistic time frame based on past performance, and make sure that the team sticks to the agreed-upon deadlines
Start Small, Think Big
Improving quality during growth requires aligning strategy with starting small. Implement incremental quality improvements each quarter. Identify the few game-changing factors that will most influence your biggest priorities.
Say no to less relevant initiatives and avoid “initiative overload.” Small gains accumulate into large transformations.
Arrange Contingencies to Promote Quality
As BCBAs, we know interventions succeed by intentionally arranging environmental variables. The same goes for elevating ASDQ; leaders must align employee, client, and financial contingencies toward quality-dependent KPIs. This includes staff incentives for retaining talent and public reporting on quality metrics to reinforce an internal culture of excellence.
With evidence-driven metrics, ABA organizations can elevate clinical quality and financial performance together.
The following missions do not need to be constrained by myths of inevitable financial tradeoffs:
- empowering individuals
- dignifying staff
- reinforcing quality of life
As you reflect on your organization’s aspirations, consider asking with ambition: How can we advance across all priorities in tandem?
