In the last year, I have visited approximately 40 ABA clinics, and have spoken to countless leaders and business owners about the struggles they face on a daily basis. I would have to rank the topic of this blog as part of the top 5 issues I get asked about every time I stop in, easily.

Cancellations. Or session fulfillment, if you want to focus on the positive flip of the measure.

And it’s entirely understandable that this is a hot topic in clinical circles! Without fulfilling clinical sessions, the typical ABA clinic cannot continue to keep the doors open. The revenues of the company are impacted with each session skipped, and both employees and clients are left wanting: the employee missing potential pay that will not be reimbursed if the session isn’t rendered, and the clients missing the critical time necessary for making progress on their programs and making gains in their skills/reductions in “problem behavior”.

Unfortunately, there is no magic wand that can be waved to resolve this serious issue. It’s complex; way more complex than one may expect. In this blog, I’ll describe some steps you can take to start resolving issues that you may be experiencing around session cancellations.

 

The Analysis

To begin resolving the cancellation issue, it’s important to determine what the issue looks like at your company. This requires (*gasp*) looking at the data to start making an appropriate diagnosis, so we can select the intervention that will be most effective for your team. In most companies, these data are already being collected in some form, so I would think carefully about what these data look like for your business currently, and perhaps based on the recommended analyses here, you may be able to enhance the data you collect in the future.

The first analysis I recommend is sorting the data by who is initiating the cancellation: the caregiver or the staff member. This may seem obvious, but in several situations in which I’ve helped troubleshoot these types of problems, the organizations were shocked to see that the opposite of their expectation was occurring. You may find that your staff members rarely cancel, but your parents often opt out of sessions. Or your case may be entirely the inverse, and your staff members are cancelling left and right, with caregivers are following through just fine. This analysis is crucial in order to determine where to focus our efforts early on – with whom we can get the most improvement. Also, historically, staff members lose motivation quickly when they are blamed for parent cancellations, and vise versa. So let’s target the appropriate population first!

The second analysis I like to do is a little more complex, but I recommend if this is a major issue for you, that you take the time to break the data down in a fashion similar to what I’m describing here. In my experience, I have determined a few crucial dimensions of a cancellation (beyond determining the party who initiates the cancellation as described above). These are:

Voluntary or involuntary. A voluntary cancellation is one in which the cancelling party is choosing to the cancel the session; for example, a staff member calling out because they would like to study for an upcoming test or go fishing, or a family deciding to go on a trip. Now, I want to say up front that I’m not against voluntary cancellations or wellness days; we just want to minimize their impact on the business and the client’s progress.

In contrast, as you may have guessed, an involuntary cancellation is an unpredictable or non-preventable reason for not holding session. These may include staff, client, or caregiver illness, a college exam scheduled during session time, car trouble, doctor appointments, etc. Typically, involuntary reasons for cancellation are met with greater understanding and compassion than someone choosing to not hold a session.

With or without documentation. Both voluntary or involuntary cancellations can have documentation associated with them, like doctor notes, mechanic receipts, exam schedules, and more. Having some expectation of documentation, particularly for involuntary cancellations, can reduce the likelihood of people “gaming the system” we will describe later in this blog. Another important note – we don’t want to eliminate or punish ALL involuntary cancellations or absences without documentation; we simply want to reduce their impact on the organization.

Last minute or ahead of time. These two are fairly clear in name, but the definitions can vary within your business. Last minute cancellations are typically within 24 or 48 hours, but you’ll better determine how “last minute” is defined for your business.  I’m sure you are familiar with the scramble associated with last-minute types of cancellations – trying to find coverage, or trying to help the staff member find additional ways to reduce the economic impact to their income. Not. Fun. Let alone thinking about the costs in company time and morale associated with this scramble… Those cancellations made with sufficient notice are much easier to handle, like pre-planned vacations or time off.

There may be more dimensions to this issue than these three, but thus far I have found the above to be the most critical components of a cancellation. By looking at your existing cancellation data and categorizing them in a manner similar to this, we can paint a much more vivid picture of what is happening in the organization, which should influence how we move forward with intervention.

 

Intervention Planning

Hopefully at this point you have an idea of what story your data tell. Regardless of who the canceller is, the interventions can be similar moving forward, with the target of reaching the follow goals:

  1. Greatly reducing last-minute voluntary cancellations. (Not eliminating!)
  2. Reducing last-minute involuntary cancellations WITHOUT documentation. (Again, not eliminating! IT happens.)
  3. Slightly reducing voluntary cancellations made ahead of time (but NOT punishing!).
  4. Reinforcing involuntary cancellations made ahead of time with appropriate documentation.
  5. Increasing appropriate rescheduling behavior (more on this in a moment). 

By this time, hopefully your data have provided a decent baseline of what these look like. From there, and in partnership with your finance department, you can set meaningful and realistic goals for the organization to hit related to cancellations. For example, we want to reduce our voluntary last-minute staff cancellations by 50% next quarter, and increase the number of caregiver cancellations with appropriate documentation by 50% in that same quarter. Remember your SMART goals – they should be specific, measurable, attainable, relevant, and time bound! Most important here are making sure the goals we set are attainable – 100% reductions or increases are simply NOT feasible in many businesses – and adding the time component that ensures we have a clear idea of when we want to assess the data and set a new goal.

It’s important to involve your finance department here to determine the bare minimum expectations around these measures – how many hours to we HAVE to fulfill in order to keep the doors open? How many hours keep us in the “black”, allowing us to potentially set aside cash to provide monetary bonuses or other reinforcers for these behaviors?

From there, you can determine an acceptable number of cancellations for each category. I recommend not setting too small of a “observation” window – quarterly is usually perfect. The following data are only hypothetical, but gives an idea of what this may look like for you:

 

Voluntariness

Documentation

Timeliness

Allocated Sessions (per quarter)

Voluntary

With or Without Documentation

Ahead of time

Case-by-case

Last minute

3

Involuntary

With documentation

Ahead of time

Case-by-case

Last minute

Without documentation

Ahead of time

3

Last minute

3

 

There are a few things you might notice in this conceptualization:

First, voluntary cancellations are treated similarly regardless of whether documentation is provided or not. If they are choosing to not have the session for personal reasons or otherwise, this isn’t really any of our business. This is their choice. However, we do want to reduce this happening at the last minute to avoid that scramble I mentioned earlier, and allow us to get coverage or reschedule in order to retain the hours if appropriate.

You’ll notice that voluntary cancellations done ahead of time do not have a specified allotment and are handled on a case-by-case basis. This allows for leniency of the policy, while avoiding this being seen as a pool of free days off from session. If this is a major issue for your organization, I welcome you to add a limit; however, I would be careful sharing this with staff or parents, as we don’t necessarily want them to take the limit each quarter.

Second, you’ll see that involuntary cancellations with documentation, regardless of the timeliness, are treated on a case-by-case basis – again, allowing for leniency for unforeseen circumstances. This should make sense: it happens. If you believe this will become abused, then by all means, add an allotment; however, in my opinion, if they are able to provide documentation in either case, we should be compassionate and considerate to both staff and parents.

Third, involuntary cancellations without documentation, regardless of timeliness, have the most restriction primarily due to the likelihood that these tend to become abused most quickly – no documentation means free day off! So I tend to put a limit on these allotments, and balance them. You may feel free to add additional allotments for involuntary cancellations without documentation made ahead of time, but I would not allow for too many last-minute document-less cancellations.

So, in the above scenario, the cancelling party basically ends up having, per quarter:

  • Potentially unlimited voluntary cancellations, if given ahead of time (this is mostly for parents, you may want to integrate your vacation/time off policy for staff here).
  • Three last-minute voluntary cancellations (again, this may not be ok for staff – but if you are trying to prevent burnout, it is nice to have the option to take a mental health day, but it’s up to your business to determine if this is feasible).
  • Potentially unlimited involuntary cancellations with documentation (given these are not preventable by definition, you want to be compassionate, but if it becomes a pattern or the documentation begins to look questionable, you may want to have a chat with the staff member).
  • Six involuntary cancellations, three ahead of time and three last minute. (If you choose to increase one of these, I recommend you allow for more leniency with those who give more notice, of course.)
  • BONUS: You may add additional leniency for rescheduled sessions as well. Ultimately, we want to minimize the impact to our bottom line, so specify under which conditions a reschedule may benefit them, and then train them on the procedures for rescheduling! Never assume someone knows how to reschedule, even if it seems very obvious. Role-play the conversations associated with the procedure, and ensure they understand not to excessively pressure or inconvenience a caregiver into a reschedule.

Remember that my numbers here are purely hypothetical. Regardless of where your numbers land, you’ll want to check with your finance department to ensure these numbers won’t bankrupt your business, of course! And this will vary from business to business, from culture to culture, and for different leader values. I do believe this strategy allows for the greatest amount of compassion for caregiver and employee situations, acknowledging that things happen! Often, in absenteeism policies, there is no differentiation between how different types of absences are handled – hopefully this structure may help you conceive a strategy that works for your organization.

Now it’s time to develop the policies based on the information you compiled. When developing a policy, I like to use the same structure as my feedback delivery strategy – it should answer “What? So what? Now what?”:

  • What? What behavior is the policy pertaining to?
  • So what? Why is this behavior important? Why is it significant to the organization or client or employee?
  • Now what? What do we need to do moving forward?

The “Now what?” here is important: what do we want them to do moving forward? What are the consequences for not following the policy (i.e. cancelling excessively)? What do they get if they follow the policy? Everything we’ve discussed up to this point is based on antecedents only, but antecedents don’t maintain behavior! Can we offer them something for adhering to the policy? Think this through carefully, and consult with your finance and HR/legal folks to see what they advise as well.

In addition to adding consequences, feedback in this area can go a long way. Consider providing quarterly reports with graphs of their percent fulfillment (I always go for the positive), and even add a goal or target line to work towards. Providing information about performance can be effective for increasing performance!

Finally, if you continue to see performance issues, take time to do a full assessment of potential barriers, using a tool such as the Performance Diagnostic Checklist to determine the contributing variables. With the above analyses, you should be able to provide clear expectations and goals, feedback and current performance information, add positive consequences, and teach them strategies that can reduce the likelihood that they will call out. Removing obstacles is crucial, so take time to talk with people who may be struggling to keep their appointments and help and reinforce, rather than blame and punish.

 

I hope this has been helpful, albeit lengthy! If you have any questions or comments, please don’t hesitate to reach out to us through our contact form. The conceptualization is always changing based on feedback, so I would love to hear from you!

 

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