Episode 44: Leading Through Change with Dr. Breanne Hartley

She speaks nationally on topics, highlighting ways in which BCBAs can effectively structure clinical work in practical settings, and she co-authored a book, The Training Curriculum for Supervisors of ABA Technicians and Autism Programs. She's a board member of the Behavior Analyst Certification Board and a committee member for the Autism Commission on Quality. Breanne, welcome to the pod.

And you ended up having a presentation after, and then, you know, one thing led to another, we got to catch up. And I'm just, I'm psyched that you're in my orbit

But I wanted to give you, you know, all sorts of accolades at the end to let you know how much I enjoyed your content, but like you said, we were able to kind of catch up at least at some point.

Is that I was, uh, originally I came to the state of Indiana to be a clinical director for an organization called The Verbal Behavior Center for Autism. Um, that was a nonprofit organization.

Little Star is a nonprofit organization, Little Star is a much larger nonprofit organization than the Verbal Behavior Center was and so essentially, after I spent about seven years at the Verbal Behavior Center, that organization merged into kind of, folded into Little Star Services, really kind of taking two non-profit entities providing very similar services in the same area, Indianapolis, Indiana, and really kind of combining the resources and, um, our abilities to provide services not only

in the Indianapolis area, but then beyond that, across the state of Indiana and and beyond. So, I was really fortunate back in 2015 to be a part of Little Star, which was pretty mature at that time. It had been, uh, established since 2002, so it was 13 years old at the time, and so I felt really privileged to join both myself, my, uh, colleagues from the Verbal Behavior Center and the patients that we were providing services to.

I really felt privileged to join this mature organization and really help it, uh, continue to grow, continue to expand, continue to evolve the services, uh, that we were providing. And so, you know, a lot of really, amazing and fantastic learning opportunities in my time.

Thus far within the organization, and I would say really at this point, my most significant takeaways are learning opportunities within my role, specifically in the chief clinical officer role, is just how crucial, um, systems are the development of really well defined systems to guide teams.

As organizations grow in the scope of services, in the location of services, as teams get bigger and more diverse, maybe not just having behavior analysts, but also including administrative support teams, for example, really the establishment of, uh, systems and looking at organizational behavior is just so crucial and I reflect often on my, the way in which I was very naive, I guess, as a graduate student because I had the privilege to get my graduate degree, uh, from Western Michigan

University and I learned from some of the greats in our field and had the opportunity to take several, uh, systems analysis courses, organizational behavior management courses, and why I say I was naive at the time is that I enjoyed the content, enjoyed those courses, but I was thinking to myself like, I'm never gonna use this. Like, isn't this cute?

You know, that we, you know, have these classes on top of the clinical courses associated to directly working with, you know, individuals with autism and developmental disabilities and lo and behold, those are courses that are really the foundation of a lot of the work that I do day in and day out to support the clinical services to support my team members within the clinical department and so yeah, those systems analysis courses, you know, taught by, I know John Austin was a, a member of

podcast, guest recently had the opportunity to learn from him, from Alice Dickinson, from Eric fox, I mean, really fantastic people that I, again, just draw on that knowledge, um, every day and those have been my learning opportunities. Systems analysis, the development of systems, and then really broadly, like don't ever take knowledge that's coming to you for granted, or assume that you're never going to use it because likely you'll use it at some point.

So keep your eyes and ears open and be very attuned to new information that's coming your way.

What's so interesting, Breanne to me about what you're describing so I had that same view as like earlier in my career and, and I think there's this sense with entrepreneurs right, and with, with those that start an organization, you can just like brute force, right to, to, to grow an organization and to, to, to do what you need to do to shape it, and the reality is, yes, you can do that, but only up to a certain point.

And the point at which you can't as an owner, um, or a chief clinical officer, like touch everyone, every team member, touch every family, and you're only as good as your weakest systems. Um, and so, and, and now I see this all the time in, in our field as well, but have you found that it's hard, you know, what does it take to really instill in, um, in a culture of an organization this idea, like this leaning into systems? Cause it doesn't come naturally to your point.

And I think just one of the interesting things in working with clinicians, with, with BCBAs is that we're trained to think very, individually about the services that we provide to each individual patient that we have the opportunity to provide services to. And that's so important, absolutely. There are individual nuances and whatnot, but kind of having a framework in groundwork in having, really consistent strategies for the way in which we put our work in place.

You know, can we create templates for ourselves so that we're not literally recreating the wheel every time? Can we start beyond ground zero, so to speak? And so really helping to instill that value, uh, within, uh, the group of BCBAs that I have the honor of, of supervising and, and leading and really helping, clinical folks have an understanding of what are you uniquely qualified to do and where does your skillset come in.

In that, you know, these templates, the standardization, these systems building, it helps you as a clinician really utilize your skill set to the best of your ability. You, you don't need to be bothered by some of the minutia or laying the groundwork. You can just jump right in with using your clinical skill set and knowledge that you have spent a lot of time honing. So that's really, um, a lot of what I talk to my team about very frequently and, and for very long periods of time.

Uh, that's been another, learning opportunity in my role just professionally, but certainly also with Little Star, is that, um, you know, you certainly as a leader, uh, can't expect to say something once and have it stick and have it land. It's continual communication, talking about it differently in different formats, individually and in groups um, having people, uh, giving folks the opportunity for question and answer. Like, Let me unpack this.

Let me give you some of my kinda individual examples. So it's really that communication very widespread, is another learning opportunity. I could just continue to unpack that gosh, so many learning opportunities, right? When we really stop to reflect on it.

So doing that consistently and in a variety of different formats, From emails to verbal to whatever, it's sending selfie videos, like so important to reinforcing those values and that's only this idea of building a culture around commitment to systems in many ways is a change management initiative and I know you did a presentation at CASP on change management, which I unfortunately I wasn't able to be there but, tell me a little more Breanne about what's one of the hardest changes you've had to

lead your organization through and, and what'd you learn from that experience?

So in the past several years ago, we would think about caseloads as the number of individuals that a BCBA is providing services to. So whether it be 5, 8, 10, 12. Okay. That's the caseload we're gonna identify, let's say, for example, at, you know, 10 patients is what a caseload for our BCBAs is.

And what we identified is that, well, there's a lot of variability in 10 different individuals that we provide services to in terms of the, um, profile of that individual as a patient, the intensity of services that they're receiving, the, maybe challenging behavior that they demonstrate and whatnot.

But the, the biggest area of kind of variability was, well, some patients could receive maybe 20 hours of therapy a week, others 25, others 40, and just kind of how things maybe shook out you could have one BCBA that has 10 patients with, 40 hours each a week of therapy and then another BCBA has 10 patients with 20 hours a week each of therapy. There's big differences in terms of the way in which a BCBA needs to manage their time to provide supervision to those different levels of, intensity.

And so, the change that we instilled was, rather than thinking and talking about what is a BCBA's caseload, um, it is a number of patients on a caseload. We shifted to, it's a number of therapy hours total that a BCBA is supervising. And so now we talk about it as a certain number of hours that a BCBA supervises in a given month, that there's a certain expectation this month and it's not BCBA supervision. Those aren't the hours that we look at.

It's the actual number of therapy hours that a BCBA is ultimately supervising. And so that, I mentioned was something that we did and it's a change that we implemented several years ago, but that's an example of something that I continually talk about. I continually, give different examples. I continually reference, whether it be in group context or in, individual meetings and discussions with folks as we're looking at their particular caseload.

It's something that it requires, uh, an opportunity to kind of talk about and think through in multiple different ways, and it requires multiple different supports for a BCBA to be successful in not only thinking about the caseload that they manage in a different way, but to actually be successful in achieving those expectations and meeting those results.

So supports from say, our insurance department who's giving them information on here's the number of hours that you have on your caseload right now, and here's kind of what you actually provided versus what's authorized. So there's just an example of how the BCBAs get information and supports from a department outside of the clinical department. But yes, absolutely. I mean, that's just one example, but I think one that's, been a good learning opportunity for me in that.

You know, 2018, I think ish is when we made that adjustment. Well, now, four years later, it's still something that we talk about and have to kind of get, get used to.

Are you crazy?

So I, I love hearing that you, um, I mean not only that, that you know, that you shifted your thinking around that model to better represent the amount of work that has to happen, Especially like for a new kiddo, 40 hours a week and you've got two or three new RBTs on the case, there's way more time that goes into, hey, that kid who's been with us for a year or two and you know, has a couple veteran RBTs that you're continually sort of reinforcing that and, and that's a, that's a really

important part of change management and where back in my career I failed when I didn't emphasize enough the why. And just like a short amount of time on why, and just went directly to the what so important to be communicating the why to our teams. how do you do that around the why?

You have this knowledge and you have this ability to truly inspire and change the lives positively for the patients on your caseload.

And what a disservice it would be if we were to identify that you aren't maximally utilizing your expertise and if we were to define it by the number of patients you have versus the total number of therapy hours you provide services to, you know, we'd be doing ourselves a disservice because we can't quite see are you able to utilize and maximize your expertise to the best of your ability.

So kind of taking it from the lens of the BCBA and the expertise that they have, but then also taking it from the lens, the why associated to our mission as an organization. So we have an A mission to inspire, serve and guide all those touched by autism to achieve a better reality.

We can't do that to the best of our ability if our clinicians aren't utilizing their skillset in the very best way possible and really managing things in a way that allows them to reach as many individuals with autism as possible. So absolutely the rationale, the why, it has to be a part of change and change management. And if you, as the person instilling the change is kind of scratching your head like, you know, why? why are we doing this then don't go communicating to your people yet.

You know, figure that out. Figure out the why, and then circle back to your group.

Doctors have to operate at highest and best use of, of their license and leadership the same way that BCBAs and others have to, And I, and I think this sentiment is, is coming around in our field and I appreciate champions like you, Breanne, who are helping us understand that and understand that medical model. That feels really important, doesn't it?

We have, you know, some limitations of being able to apply behavior analysis outside of individuals diagnosed with autism that, so that could be a whole separate conversation.

But when I think about, um, a medical model, I'm thinking about, well, we have an individual diagnosed with autism because of various DSM criteria that they've, met and so now we have as clinicians as providers, we have an obligation to, evaluate what those symptoms are that are, inhibiting their ability to lead maybe as fulfilling of a life as possible.

And, and when I think about, um, the parallels to, okay, well what can we as behavior analysts learn from the medical field is again, this standardization. So we talked about systems development. I think a lot of, uh, when you're establishing systems within an organization, it's centered around, well, how can we standardize what we're doing? And when we standardize things, I think that helps to, kind of set things apart.

as far as, um, kind of the differences between maybe an educational model and a medical model, like in medical practice okay, here's generally how we're gonna respond to maybe these specific deficits, or when we see these specific symptoms, this is generally how we're gonna respond.

Of course, we'll sprinkle in the individuality and that's absolutely important as well but standardization even in the sense of, okay, well we have a, a treatment plan that's that's helping to demonstrate how we're looking to remediate the symptoms of autism. And so, um, Medical professionals who have to write essentially a treatment plan or at least demonstrate why it is that, uh, an insurance provider, for example, should reimburse the services that are being provided.

And so I think that's, that's warranted for us as behavior analysts to um, be able to systematically be able to describe why we're providing the services, why we need a certain intensity of the services that we're providing. So dosage, uh, is, is a kinda medical term, you know, thinking about a medical model well, dosage is important to us as behavior analysts.

We need to be able to determine why does this patient need X number of hours of therapy per week and this patient needs y number of therapy hours per week. You know, we can't just, rely clinical judgment. There's a lot of gray area in clinical judgment. It's kind of like use clinical judgment with some established standardized tools to then blend and determine what it is that you're doing and how much it is that you're doing.

Breanne, so you've helped me, um, give me a better language to describe that transition and, you know, use that word that's really important when it comes to systems, which is standardization, which can also be a scary word, I feel like. Especially knowing that like all of the treatment we provide is so highly individualized. And yet systems, they, they incorporate standardization, but that doesn't mean everything is exactly the same. The systems have to be able to adapt and adjust.

Same way, the human body I played softball last night, right? and had five at bats my lower back, I'm gonna tell you, did not feel like when I took five at bats back in my twenties. Like the system, the body systems have to change and adapt. So there's, it's possible to have this duality. Yes, standardization existant systems and systems have to be flexible, and have to be able to adapt to their environment.

Well, let's come back around to the idea of change and, Jack Welsh, who was the longtime CEO of General Electric, and he's got a quote that said something about the, If the rate of change outside an organization exceeds the rate of change inside the organization, the end is near. Oh. Which sounds kind of like, gives be the goosebumps still, but you know, our field has gone through rapid and profound change over the last decade, two decades.

How do you keep up with that rate of change inside an organization?

I have the opportunity to connect with folks like you and other CASP members and other professionals in the field and get a sense of kind of what is the changing landscape, what are some of the things that are happening that I need to be aware of, and then help influence internally within the organization?

Well, uh, oftentimes my colleagues, uh, BCBAs, who for example, maybe hold a caseload, uh, of individuals that they're providing services to, they don't maybe have as much of that opportunity to see externally and kind of get a sense of what's happening outside the walls of Little Star so So I feel, um, the responsibility and the obligation of like, Hey, here's what's going on. You know, here's what's happening out in the world.

Here's what we need to be maybe aware of and mindful of and so certainly that's, that's one thing, um, to help, ensure that we can internally within the organization, keep up with the rate of change. And then it absolutely is a focus on a culture, uh, and a value of continuous quality improvement. So it is something that was instilled with within me, uh, in my graduate school experiences, continuous quality improvement. We can. Always, always, always work towards making things better.

We're never going to be complacent just with like, you know, I think we're good I think we're just gonna kind of like wash our hands of this. We can step away. You know, there's always going to be opportunities to improve. And so that's, uh, a value that I instill within my team members, like at probably at least weekly uh, at a minimum, they're hearing me talk about continuous quality improvement. You know, this is amazing what we're doing now but we can make it better.

Like we can, we can tweak here, we can make adjustments. And so I say that as an example of, you know, change. Well change is improvement. If you think about the, you know, synonyms of change, betterment, improvement, and so that's really just kind of reframing things a little bit and that, yeah, the world is gonna change and do things around us, and that's okay because we're ready for it.

We're nimble, we're flexible, we're, we're excited about the opportunity to change because that means that we're getting better. So I think it really is just creating that, that culture, that awareness, that value.

Um, and we can't always control those the external environment, What can we control Is how we prepare for change and how we build that culture, um, in our organizations. That feels really powerful.

Um, I don't know the degree to which you could share, like what was it like being at a BACB board meeting, um, but then really importantly, what's your biggest goal that you hope to achieve during your board tenure?

Um, and the board members, some I had already known and had interacted with, uh, you know, my previous professional interactions and some were brand new to me and so it's just a really incredibly, um, dedicated, passionate group of people who are just so invested in, uh, betterment, I guess change, uh, improvements for the field.

And so, Uh, yeah, overall just has been a wonderful experience thus far and as far as, you know, kind of things that I would love to see, uh, the, for the BACB or in terms of my role, uh, as a board member for the BACB, uh, I, I first have to give a quick disclaimer is that I'm not, speaking on behalf of the Behavior Analyst Certification Board. I'm speaking on behalf of myself.

Um, but yeah, really just love, um, the thought of seeing the Registered Behavior Technician credential continue to get, um, more, meat behind it, you know, what, uh, what really is required in terms of becoming a registered behavior technician. How do we, as a credentialing body, help to prepare them, for the role that they will have as they start, uh, uh, patient facing? And then what are maybe some things that the BACB can do to help influence more longevity in the RBT roles?

So we're seeing that it's approximately a third of BCBAs will not renew their, uh, certification after one year. So it's really a, I mean, I think we, those of us who are, are practicing and interact with rbts, I think we know that there's a fair amount of turnover, but to really have an understanding that a third of folks that we're welcoming into the profession today won't be, uh, continuing a year from now.

I think that's important for us to be aware of and think about what are some things that we can do to help influence that. And I think that the BACB is very aware of what their scope is. It's a credentialing body, a certification, body and so there's uh, a need for kind of partnerships with other maybe organizations in terms of some of the real hands on kind of practical work and, and work of practitioners.

CASP, but you know, again, something you and I are both involved in does a wonderful job of really kind of, taking a hold of those kinds of issues.

What are practitioner issues, but overall, whether it be through BACB work, CASP, or any other, um, entity, you know, I think really kind of doing a, a focus and a double down on, on the RBT role and kind of what can we do to maybe increase the public awareness of what a registered behavior technician is to further promote folks, to find this profession and, and, and do the amazing life changing work that registered behavior technicians do.

Uh, those kinds of things I'd love to see happen down the road.

What that tells me is like there's something that we, and I say we, like me and, and provider organizations maybe are also not doing sufficiently to prepare RBTs or, you know, behavior technicians to come in to the field and become RBTs and, and look, I get it like this is, I honestly think being an RBT is one of the hardest jobs in the world. Um, and disclosure, like I, I've never been an RBT I've seen tons of sessions and I've gone through a chunk of the, the trading. Um, but.

I mean, is, is that part of the solution that that providers, um, are helping RBTs number one, understand how freaking hard this work is? And then number two, designing training programs, to ensure that they're fully prepared to be successful in addition to what clearly has to be lots of ongoing support and high quality supervision. I mean, is that part of the answer? What's your, what's your thought?

Um, in comparison if, uh, to, if they were to apply for a, say a retail position. Like I, I have a general sense of what retail is or like, I've seen lots of people who work at retail places in my life, like I have models for what that consists of. But have you seen in actuality a registered behavior technician doing the work that they do? Probably not.

And so that certainly is something that within, uh, Little Star we're taking a look at to determine how can we better educate folks through the application and the interview process.

Can we create some, um, videos and whatnot to, uh, help them kind of understand, can we do maybe a lengthier tour of our center so that they can observe and get a feel, uh, for what the work will consist of, because, Unfortunately what we're experiencing, and I would like to imagine that we're not the only ones, is that there's a certain, percentage of the folks that we hire who don't make it past a month.

You know, I think that is a indication that they just sort of identified, actually, this isn't for me, or this isn't what I thought it was going to be. And so we're actively looking at those things and trying to decrease the number of people who leave within a first month because we can better prepare those applicants and better, provide them information on what the role will consist of.

When you studied at Western Michigan, and was it 2005? 2009? Jim Carr was there, John Austin, we mentioned Linda Leblanc. I mean, this seems like the Pantheon of like out of behavior analysis. Did you get to study with each one of them and I tell, tell me more about your education and learning.

We learned from just these incredible people and how lucky were we? I mean, at, at, right, at Western Michigan University in that era, it was just like rockstar after rockstar and so I, uh, just, I, I now completely cherish that and, and really value those graduate experiences.

Certainly our field has shifted in that direction from more of an educational model and I think we're likely to go deeper and deeper kind of into that medical model, which will likely include um, things like value-based care initiatives, which is important and it's good and we need, we need to, as a field, kind of continually look at how are we evaluating the, uh, outcomes that our patients are obtaining and what is the value that the patient gets?

Uh, are we doing it in a really proficient way that utilizes our staff and, and their expertise to the best of our ability? And so, you know, how do we prepare for that as a field? Uh, one of the things that I've started to influence within Little Star is establishing key performance indicators for our BCBAs that are fully centered around their patients outcomes.

And what, what are the progress, measures that patients within a caseload are making and ensuring that our BCBAs have an understanding that that is their expectation. I, I mean, I think it without having to say it, certainly people understand, but, but creating, um, benchmarks around that. We have a, a performance scorecard system within the organization, and that always evolves over time.

And right now the, the current evolution and iteration does have a heavy emphasis on, you know, what are you as a BCBA able to do to fully directly influence the, the progress of your patient. So I think those are some things that we can, be doing as a field. Not only, you know, very broadly looking at, well, what are patient outcomes? How do we measure that? What does that consist of? All of that is so important, but making sure that we get more granular.

Really, um, influencing our BCBAs to be thinking about what can I do to ensure that my patient is progressing down to, you know, some of the minutia. Like what are my, um, clinical decisions that I'm making? How often am I making clinical decisions? Am I looking at, um, the rate of progress for my patient as often as I should be? And so those are some of the things that we're looking to influence as far as, um, performance expectations.

let's look to see, um, kind of historically what say the medical field or the psychology field has done and, As I've become more interested in those kinds of things you know, the, the medical field has been around since the 1600s the psychology field per se, late 1800s you know, formally behavior analysis, uh, has only been around since 1998 if we think about the BACBs inception, like sure, we've had the science for several decades, but sort of formally solidifying behavior analysis as a field,

I think really can be marked with when we had certification to kind of acknowledge that there are these people that can do this work. So 1998, that's only 24 years ago. Uh, I mean, essentially behavior analysis can't even rent a car, you know, on their own if we kind of frame it in that way. So really thinking about, okay, there's hundreds of years of history that we can learn about if we look outside of the field, And so I think, right, we need to start doing that more.

There's so much to learn from history and the systems that other fields have established, and, and I think that's important.

And it's something that I remember my dad listening to when I was a kid and now as a parent I can resonate with the lyrics and really just the sentiment associated to embrace every moment of every day. Don't say, Oh, I'll, I'll get to it tomorrow I'm gonna hang with the kids tomorrow. Hang with the kids today. They're only little for a short period of time. Fully, um, yeah fully live life today.

And I suppose I just wish that, maybe I realized that a little bit, uh, sooner in life.