Compare Treatment Integrity Across Care Settings

To compare treatment integrity across settings, use the same procedure version and eligible-opportunity definition or explain every difference. Record materials, partner roles, schedule, risk, observer, sample size, access, authorized adaptations, and client experience. A lower score in one setting may identify a contextual barrier or a poorly fitted procedure. It does not automatically identify weak implementation.

Map common and setting-specific components

Identify which steps should remain constant and which legitimately differ because of role, environment, consent, access, or safety.

Build a crosswalk that shows the shared clinical mechanism, accepted client responses, partner actions, and justified adaptations. Label the active version and effective date for each setting. A different step is not automatically an integrity error when the qualified plan allows contextual variation. Conversely, the same written step may be inappropriate if the environment changes its meaning or feasibility.

Review the crosswalk with people who know each setting and with the client through accessible communication. Identify rules or routines that cannot be changed locally and questions needing school, medical, workplace, privacy, or other authority. Document the qualified decision about each adaptation so observers do not substitute personal preference for the governing plan.

Match opportunity types

Compare the same cue and decision window. A clinic-created trial and a naturally occurring community opportunity may require separate series.

Define what makes an opportunity valid, which outcomes are available, and what support or partner must be present. Report opportunity counts, exposure, prompts, client decline, and missing contexts by setting. When natural events occur at different rates, compare component performance within matched opportunity classes rather than using one pooled percentage that rewards the easiest environment.

Sample at times and with partners representative of actual use, including ordinary variability when safe and feasible. A quiet, prepared clinic observation may not predict a busy community routine. If matched opportunities are rare, extend the window or report settings separately. Preserve the question of generalization without forcing incompatible evidence into one conclusion.

Measure setting supports

Record materials, space, noise, staffing, partner availability, AAC, mobility, privacy, and timing. Missing infrastructure should not become a personal deficit.

Inspect actual availability during each observation, including connectivity, device charge, sensory conditions, transportation, and backup procedures. Assign repairs to the roles that control the environment. Keep client access and immediate safety supports available while problems are corrected. Repeated setting failures may call for schedule or plan redesign, not merely more coaching of implementers.

Interpret with client experience

Pair integrity with Orla's feedback, participation, effort, adverse effects, and outcome in each setting. A high setting score may still reflect poor fit.

Ask which context feels useful, comfortable, private, and sustainable through accessible communication. Separate the client's report from caregiver or staff interpretation. Review goal response, burden, partner behavior, and access beside integrity. A lower score in a setting may expose a plan mismatch, while high fidelity with worsening experience should prompt qualified clinical reconsideration rather than celebration.

Put the cross-setting comparison into practice

Orla's home, clinic, and library observations use a shared core definition. The library lacks one material and requires a quieter communication option, both recorded as context and adaptation. The clinician compares matched components, preserves setting-specific steps, and asks Orla which setting feels most workable.

Keep supervision, quality, and employment roles separate for Orla

Orla's cross-setting integrity comparison identifies the clinical decision owner, observer, supervisor, quality reviewer, operations owner, privacy contact, and employment owner. State which process is active, what notice and evidence it uses, who may decide, and where the record belongs. One integrity observation should not silently change purpose after collection.

Protect client access during Orla's review

Orla's process keeps AAC, interpreters, mobility, food, water, bathroom use, prescribed care, health support, rest, relationships, and emergency help available. Obtain required consent and assent when applicable and follow the governing response to withdrawal or distress. Client protection can require immediate action while broader measurement and personnel conclusions remain pending.

Use raw evidence and matched denominators for Orla

Report Orla's correctly implemented components divided by eligible components due, observations completed divided by observations due, agreement pairs divided by pairs due, and repairs verified divided by repairs due. Keep procedure versions, critical steps, exposure, client outcomes, direct experience, access, missingness, adaptations, drift, burden, and adverse effects in separate series.

Ask six supervision and review questions for Orla

Use these questions in the cross-setting integrity comparison:

Which client decision, procedure version, component, and eligible opportunity apply?
Which people, settings, risks, supports, observation modes, and sample limits matter?
Which integrity, agreement, exposure, outcome, experience, access, and adverse-effect series stay separate?
Which skill, clarity, resource, workflow, safety, burden, supervision, or plan-fit barrier is supported?
Which clinical, quality, operations, privacy, employment, certification, or payer owner may act?
Which repair, stop rule, follow-up evidence, and review date close the loop?

Keep unresolved evidence visible with a state, owner, age, and next action.

A fictional supervision example for Orla

Orla is fictional and involved in the same choice procedure used at home, a clinic, and a community library. Reviewers freeze 33 version, opportunity, material, partner, schedule, access, observer, sample, client-experience, and setting fields and complete 23 of 33 by the checkpoint. Missing, unobservable, inapplicable, adapted, drifted, disputed, failed, and pending fields keep their defined states.

The cross-setting integrity comparison measures evidence completeness. It does not establish effectiveness, safety, acceptability, competence, employment performance, certification compliance, medical necessity, authorization, payment, generalization, maintenance, or causation.

Use current sources within their scope for Orla

For Orla's cross-setting integrity comparison, the CASP public summary supplies high-level individualized assessment, implementation, and evaluation scope for ABA treatment of autistic people. The BACB Ethics Code addresses competence, client involvement, consent and assent when applicable, supervision, risk, documentation, and evaluation for covered behavior analysts. The BACB supervision page routes readers to role-specific supervision and training resources; those requirements do not replace licensure, payer, employment, or case authority.

For Orla, the BCBA Test Content Outline addresses procedural fidelity as examination content; case protocols require qualified case-specific authority. The Ferguson practitioner guide supports observable components and eligible opportunities. The Essig, Rotta, and Poling review supports caution in fidelity-report interpretation. ASHA says AAC users should always have access to their tools or devices. Set coaching triggers, comparison rules, and performance thresholds from the current case and setting.

Close Orla's review

Ask Orla, the implementer, and the responsible clinician to review the cross-setting integrity comparison through accessible communication. Record the evidence, perspectives, limitations, selected repair, responsible system, clinical decision, follow-up observation, client outcome and experience, and review date. Reopen the analysis when the procedure, client priority, access, health, setting, implementer, supervisor, risk, or outcome changes.

How to Compare Treatment Integrity Across Settings