Interview conducted by David Celiberti, PhD, BCBA-D
Association for Science in Autism Treatment

 

Dr. Erick Dubuque, Autism Commission on Quality

As this issue of Science in Autism Treatment is dedicated to the Council of Autism Service Providers (CASP), I am thrilled to feature an interview with Dr. Erick Dubuque. As the leader of the Autism Commission on Quality (ACQ), Dr. Dubuque brings considerable experience to advancing quality in autism services. In this interview, we will delve into Dr. Dubuque’s transition from academia to the ACQ, discuss the genesis and goals of the ACQ accreditation program, and discuss how it aims to improve the experience of autistic individuals and their families by promoting access to high quality services.

David: Can you share a bit about your career path prior to your involvement with the Autism Commission on Quality (ACQ)? What led you to change course and assume a leadership role with the ACQ?

Erick: Prior to joining the Council of Autism Service Providers (CASP) and leading its non-profit accreditation program, the Autism Commission on Quality (ACQ), I was an assistant professor responsible for directing, teaching, and conducting research within applied behavior analysis (ABA) master’s degree programs. I also served as the part-time administrator for the Association for Behavior Analysis International’s (ABAI) higher education accreditation program, chair of the Kentucky Applied Behavior Analysis Licensing Board, and president of the Kentucky Association for Behavior Analysis (KYABA). I left academia to help start ACQ, because I was deeply troubled by the variability in service quality occurring within our industry. I thought I could have a bigger impact promoting our science and practice by helping facilitate the creation and enforcement of industry standards that would increase access to quality services.

David: That is very impressive and your commitment to quality and improved access resonates deeply with us here at the Association for Science in Autism Treatment. What gave rise to the ACQ?

Erick: ACQ is a natural progression of the work of CASP and its leadership team. For example, CASP CEO Lorri Unumb, COO Mike Wasmer, and Judith Ursitti (former VP of government affairs) spent over a decade at Autism Speaks working with parent advocates to pass autism insurance reform across the country. It makes sense that these same parent advocates would want to support the establishment of a nonprofit accreditation body like ACQ to help ensure the access they fought so hard to establish leads families to quality services. CASP is also responsible for publishing and updating the industry’s clinical practice guidelines that inform ACQ’s accreditation standards. This includes the third edition of the ASD Practice Guidelines, released in April, as well as the Practice Parameters for Telehealth that served as a critical resource for providers during the COVID-19 pandemic and beyond. Additionally, the CASP Board of Directors and many of its most active members include many of the same industry leaders who have been advocating for accountability, access, and quality for decades across multiple leadership roles and organizations, including within ASAT. Beyond its nonprofit status with a focus on the public good, what makes CASP a natural home for ACQ is its treatment of our accreditation program as an independent entity. CASP’s leadership understood early on that firewalls between CASP and ACQ were necessary to preserve its integrity. Therefore, while CASP provides financial and in-kind support to ACQ, our operating agreement specifies that no organization, including CASP, is permitted to have control over the committees responsible for its essential accreditation activities.

David: I would love for our readers to learn about the development of the accreditation standards.  Can you tell us about how the initial accreditation standards were established?

Erick: ACQ’s accreditation standards took well over a year to develop. Our standards are created and enforced by independent committees of experts and representatives involved in receiving, delivering, supporting, and funding applied behavior analysis (ABA) services for individuals and families affected by autism. Committee member terms are staggered, and new members are appointed by the Standards Committee following an open call for nominations. Volunteers participating in the process are asked to share information about their background and experience as it relates to applied behavior analysis and autism. When making appointments, the Standards Committee reviews this information in an effort to address any potential gaps in expertise and representation. As a result, ACQ’s standards are shaped by the community we serve and are designed to address critical barriers preventing access to quality services. They are based on recognized industry guidelines and are flexible enough to accommodate and encourage innovations. Unlike most accreditation bodies, complimentary copies of ACQ’s Standards and Guidelines can be requested from our website, because our commitment is to improve services across the industry, regardless of whether an organization is ready to apply for ACQ accreditation.

David: What is the vision for how the accreditation program will improve the experience of autistic individuals receiving services? Their families?

Erick: ACQ believes individuals and families affected by autism should be able to access quality healthcare services from their ABA providers. By setting, promoting, and enforcing industry standards established and informed by diverse groups of experts and representatives, ACQ is giving providers the tools they need to improve their operations. Accreditation is not a panacea, and it will not solve every challenge preventing access to quality services. However, accreditation is an important mechanism that holds organizations accountable to the communities they serve by verifying they have established policies, procedures, processes, and systems that focus on critical areas such as patient health and safety; provider training and supervision; and compliance with applicable regulations.

David: Without divulging confidential information about specific organizations, can you give a few examples of how accreditation is applied to a small organization serving under 20 individuals versus a very large one?

Erick: ACQ’s standards are designed to accommodate organizations of varying sizes offering ABA as a healthcare service across multiple settings. ACQ’s standards are flexible enough to permit our review team to contextually evaluate the organizations applying for accreditation. For example, a larger organization offering ABA services across several states would likely have dedicated departments to address important areas like HR, financial operations, and compliance, etc. This model would not be feasible or even advisable for smaller providers serving a limited number of individuals. Instead of creating departments, these smaller organizations may have one or two individuals assigned to multiple roles. Smaller organizations could still meet ACQ’s standards by ensuring these individuals have access to the time and expertise needed to serve in these roles. For example, a small provider CEO overseeing their own human resources and financial operations may contract with an attorney to help them draw up their employment contracts or use an accountant to help manage their books. Likewise, the behavior analyst assigned oversight of the small provider’s compliance program may have a reduced caseload size and be required to participate in initial and ongoing compliance training to ensure they have the time and expertise to carry out this role effectively.

David: Can you share some details about the application process? What type of feedback is provided to organizations who are seeking accreditation? Can you offer some examples that highlight the intent and scope of such feedback?

Erick: During the application process, ACQ has multiple points of contact with the organization. We encourage communication when questions come up. Each point of contact is an opportunity for ACQ to provide feedback to the organization. Probably the most helpful feedback is delivered after the review team completes its initial evaluation and when the organization receives its final accreditation report.  Once an initial evaluation is completed, the review team seeks clarifications and shares feedback on areas where it appears the organization may not be meeting a standard. For minor issues, this step may permit an organization to make updates to align their operation with ACQ’s standards before the review team submits their blinded report to the accreditation committee for a decision on the application. For instance, a standard may require the organization to have a policy that includes three specific elements. However, the policy that was shared during the review process only includes two of those elements. Depending on the standard, the organization may be able to add the final element and share the updated policy along with evidence that verifies relevant staff have been trained on it. At the end of the process, organizations seeking accreditation are provided with a final report identifying areas of strength, recommendation, and concern. The report also shares the organization’s aggregated scores across the employee and patient/caregiver satisfaction surveys conducted as part of the review. In the report, de-identified and aggregated survey scores from previous applicants are also shared with the organization to provide them with a point of comparison. Even when an organization does not receive a favorable accreditation determination, the process is still designed to be educational. For example, an organization may learn that their behavior technicians may be committing unintentional fraud by ending active treatment 10 minutes early to write their session narratives. Or they could discover that their behavior analysts are creating inaccurate or incomplete visual displays of data because they have not been adequately trained on the practice management software being used by the organization. Or they may learn that their clinical directors are not providing the level of supervisory oversight needed to ensure its ABA services align with established practice guidelines.

David: What will guide the next iteration of the accreditation standards and guide given the commitment to continuous evolution?

Erick: The next iteration of ACQ’s standards and guide should be directed by the community we serve. That’s why we welcome feedback on our standards from individuals or groups. Those involved in receiving, delivering, supporting, and funding services are best positioned to help us ensure our standards remain relevant and meaningful. We began working on version two of our standards the same month we opened for applications. This work will always be ongoing to ensure ACQ is addressing relevant barriers preventing access to quality services. That being said, iterations to ACQ’s standards need to be handled responsibly and in a way that moves the industry in the direction set by our standards committee. That responsibility includes ensuring that our updates do not create unnecessary administrative burdens for organizations pursuing accreditation. Over time, I think accreditation itself can be used to reduce the administrative burden organizations are experiencing by promoting a common set of industry standards that will inform the various regulations and funder policies organizations are currently forced to meet. The adoption of common standards across the industry will not happen quickly. However, as a non-profit accreditation body, ACQ is best positioned to set and enforce standards to stabilize our industry resulting in a better experience for everyone involved.

Thank you for participating in this interview. We are very grateful that you were able to share your experiences and applaud the work of the ACQ in promoting access to quality services.

Citation for this article:

Celiberti, D. (2024). An interview with Dr. Erick Dubuque, Autism Commission on Quality. Science in Autism Treatment, 21(12).

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